Abstract
This case describes the management of a patient admitted to an emergency department with general malaise, who deteriorated into cardiac arrest and refractory to advanced life support measures. After extracorporeal cardiopulmonary resuscitation (eCPR) with veno-arterial extracorporeal membrane oxygenation in association with an Impella 2.5 device, the patient underwent cardiac surgery (tissue aortic valve replacement, coronary artery bypass grafting and implantation of short-term paracorporeal left ventricular assist device). Subsequently a long-term LVAD was implanted and the patient was successfully discharged shortly afterwards.
This report illustrates the challenges of ‘clinical decision making’ in a complex patient utilising a wide range of left ventricular support mechanical devices with varying degrees of invasiveness, whilst also reflecting on the current financial and economic considerations in utilizing this type of care pathway.
Highlights
- •
VA-ECMO role in refractory cardiac arrest (eCPR) as successful “bridge-to-reflection.”
- •
Modern percutaneous LVAD (Impella) in managing VA-ECMO-related LV distension.
- •
Ethical and financial issues: may eCPR generate brain-dead patients and waste healthcare resources?
A 54-year-old man was admitted to our emergency department with general malaise. His past medical history included coeliac disease and non-Hodgkin’s lymphoma. Baseline blood tests included macrocytic anemia (Hb 5.2 g/dL), thrombocytopenia, hepatic and renal dysfunction.
After 4 h, he became haemodynamically unstable and spontaneously went into cardiac arrest. Cardio pulmonary resuscitation (CPR) was initiated with the aid of the Autopulse Lifeband® System (ZOLL Medical UK, Runcorn, Cheshire, England). The patient was refractory to CPR and adrenaline. Bedside trans-esophageal echocardiography (TEE) excluded an aortic dissection, pericardial effusion and pulmonary embolism. The patient was therefore transferred to the cardiac intensive care unit and peripheral VA-ECMO initiated, with return of spontaneous beating (ROSB) shortly afterwards. A repeat TEE revealed severe aortic regurgitation and left ventricular dysfunction with elevated filling pressures.
Therefore, to help manage aortic regurgitation and left ventricular unloading, we implanted a miniaturized percutaneous LVAD (Impella 2.5 [ABIOMED Inc., Danvers, MA]) as “bridge to bridge” allowing investigations into the etiology of the arrest, severity of neurological dysfunction and likelihood of recovery.
Twenty-four hours later, the patient awoke without any significant neurological deficit. We performed coronary angiography which revealed a left main critical stenosis, subtotally occluded left anterior descending artery and severe obtuse marginal (OM) artery stenosis.
The cause of the arrest was thought to be due to a multitude of reasons including: coronary artery disease; severe aortic regurgitation (impairing coronary flow reserve) and profound anemia (affecting oxygen delivery). The cause of the anemia was later found to be due to Vitamin B12 deficiency (due to chronic autoimmune atrophic gastritis).
After 24 h of support with VA-ECMO and an Impella 2.5, the patient underwent tissue aortic valve replacement (Edwards Perimount 21 mm), coronary artery bypass grafting (saphenous vein graft to LAD, SVG to OM) and temporary LVAD Centrimag (Levitronix LLC, Waltham, Mass) implantation.
After 18 days of support with the short-term LVAD and continued rehabilitation, a HeartWare LVAD (HeartWare Inc., Miramar, FL) was implanted for long-term support. The patient was registered on the cardiac transplantation list and successfully discharged shortly afterwards. At one-year follow-up, the patient’s quality of life was acceptable: he could self-care, ambulate, and leave his home for short periods by himself.
Sudden cardiac arrest is a life-threatening event that can be refractory to existing resuscitation protocols (refractory cardiac arrest). Recent data have suggested that veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be useful in this setting and is termed: extracorporeal cardiopulmonary resuscitation (eCPR) . However, the use of VA-ECMO in the context of eCPR may not be sufficient to achieve haemodynamic stability and can lead to high left ventricular and pulmonary pressures . In this setting, some reports have indicated the use of a percutaneous left ventricle assist device (LVAD) for left ventricular unloading .
In Fig. 1 we summarize the step-by-step patient-tailored approach followed:
- 1)
This case confirmed the positive prognostic effects of VA-ECMO in the context of refractory cardiac arrest (eCPR) ( Fig. 1 – step 1). It is generally doubtful whether one should opt for eCPR in such a patient with a history of malignancy, anemia and impending multi-organ failure on presentation; however, in this case, this option proved to be a successful “bridge-to-reflection” as it allowed us to rule out a malignancy relapse.
- 2)
Our report also raises the important issue of left ventricular distension and pulmonary congestion during eCPR. Although full-flow VA-ECMO provides good support to circulation, it is well known to hamper left ventricular ejection fraction by significantly increasing systemic afterload, especially when severe aortic regurgitation is present . Unfortunately, aortic regurgitation is both difficult to recognize during CPR, and regarded as an absolute contraindication to VA-ECMO. Many strategies may be undertaken for left ventricular venting and decompression. We decided to implant a percutaneous LVAD, which was effective in achieving temporary stabilization of the patient’s haemodynamic status. Our case interestingly demonstrates that aortic regurgitation is not a strict absolute contraindication if Impella technology is quickly available.
- 3)
The next step ( Fig. 1 – step 2) was surgical short-term LVAD implantation. It might, in retrospect, have allowed us to skip the ‘Impella step’ if it had been implanted earlier, but the specific circumstances and logistics did not allow us to undertake this surgical option as easily as bed-side echo-guided Impella implantation. As widely demonstrated in literature , the use of paracorporeal short-term LVAD (Levitronix, Centrimag) as a “bridge to decision” was useful before deciding whether definitive LVAD or cardiac transplantation should be undertaken. It allowed us to investigate the patient’s hematological abnormalities that initially represented a contraindication for further procedures. We were also able to successfully treat anemia and thrombocytopenia, enabling the use of a long-term assist device, as there was no recovery in left ventricular function ( Fig. 1 – step 3).
