Arrhythmia-induced cardiomyopathy: A potentially reversible cause of refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation

Hékimian, Guillaume; Paulo, Nicolas; Waintraub, Xavier; Bréchot, Nicolas; Schmidt, Matthieu; Lebreton, Guillaume; Chambrun, Marc Pineton de; Muller, Grégoire; Franchineau, Guillaume; Bourcier, Simon; Nieszkowska, Ania; Masi, Paul; Leprince, Pascal; Gandjbakhch, Estelle; Luyt, Charles‐Édouard

doi:10.1016/j.hrthm.2021.03.014

Cited by 17 publications

(16 citation statements)

References 24 publications

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“…However, the sole criterion of Afib may not be of overall prognostic importance in cardiogenic shock [ 15 ]. On the other hand, the potential role of va-ECMO for recovery from refractory cardiogenic shock in arrhythmia-induced non-ischemic cardiomyopathy has been recently shown in 35 patients over 14 years [ 16 ]. In summary, several, not mutually exclusive aspects of the clinical scenario may have contributed to the complex pathogenic pathways possibly initiated by the myocarditis due to influenza A infection of this 33-year-old female patient and may also have aggravated her clinical course to refractory cardiogenic shock.…”

Section: Discussionmentioning

confidence: 99%

Cardiogenic shock with highly complicated course after influenza A virus infection treated with vva-ECMO and Impella CP (ECMELLA): a case report

Ebert

Mungard

Mensch

et al. 2021

BMC Cardiovasc Disord

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Background The value of mechanical circulatory support (MCS) in cardiogenic shock, especially the combination of the ECMELLA approach (Impella combined with ECMO), remains controversial. Case presentation A previously healthy 33-year-old female patient was submitted to a local emergency department with a flu-like infection and febrile temperatures up to 39 °C. The patient was tested positive for type-A influenza, however negative for SARS-CoV-2. Despite escalated invasive ventilation, refractory hypercapnia (paCO2: 22 kPa) with severe respiratory acidosis (pH: 6.9) and a rising norepinephrine rate occurred within a few hours. Due to a Horovitz-Index < 100, out-of-centre veno-venous extracorporeal membrane oxygenation (vv-ECMO)-implantation was performed. A CT-scan done because of anisocoria revealed an extended dissection of the right vertebral artery. While the initial left ventricular function was normal, echocardiography revealed severe global hypokinesia. After angiographic exclusion of coronary artery stenoses, we geared up LV unloading by additional implantation of an Impella CP and expanded the vv-ECMO to a veno-venous-arterial ECMO (vva-ECMO). Clinically relevant bleeding from the punctured femoral arteries resulted in massive transfusion and was treated by vascular surgery later on. Under continued MCS, LVEF increased to approximately 40% 2 days after the initiation of ECMELLA. After weaning, the Impella CP was explanted at day 5 and the vva-ECMO was removed on day 9, respectively. The patient was discharged in an unaffected neurological condition to rehabilitation 25 days after the initial admission. Conclusions This exceptional case exemplifies the importance of aggressive MCS in severe cardiogenic shock, which may be especially promising in younger patients with non-ischaemic cardiomyopathy and potentially reversible causes of cardiogenic shock. This case impressively demonstrates that especially young patients may achieve complete neurological restoration, even though the initial prognosis may appear unfavourable.

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Section: Discussionmentioning

confidence: 99%

Cardiogenic shock with highly complicated course after influenza A virus infection treated with vva-ECMO and Impella CP (ECMELLA): a case report

Ebert

Mungard

Mensch

et al. 2021

BMC Cardiovasc Disord

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“…Supraventricular (tachy-)arrhythmias, i.e., atrial fibrillation and flutter, are frequently encountered during critical illness and may be caused by a combination of cardiovascular failure and systemic inflammation in the setting of multiorgan failure [21]. A (tachy-) arrhythmia-induced cardiomyopathy can be the cause of severe cardiogenic shock requiring VA ECMO [22], but may also contribute to persisting VA ECMO dependency. It can do so by ablating the atrial kick, compromising passive ventricular filling and reducing myocardial contractility.…”

Section: Tachyarrhythmiasmentioning

confidence: 99%

“…Yet, restoration of sinus rhythm does not necessarily result in the immediate recovery of mechanical forces and atrial stunning may persist for days. Therefore, a 'rate control' strategy may be equally valid when sinus rhythm cannot durably be achieved [22]. An arrhythmia-induced cardiomyopathy justifies an aggressive rate control strategy, including definite ablation of the atrioventricular node, and pacing [22].…”

Section: Tachyarrhythmiasmentioning

confidence: 99%

“…Therefore, a 'rate control' strategy may be equally valid when sinus rhythm cannot durably be achieved [22]. An arrhythmia-induced cardiomyopathy justifies an aggressive rate control strategy, including definite ablation of the atrioventricular node, and pacing [22]. Ventricular arrhythmias during VA ECMO support can arise due to a variety of factors which include electrolyte abnormalities (see section 'E: extracardiac factors'), pro-arrhythmogenic side effects of medication, myocardial ischemia, novel structural abnormalities or complications (see section 'D: dysfunction of mechanical origin').…”

Section: Tachyarrhythmiasmentioning

confidence: 99%

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The ABCDE approach to difficult weaning from venoarterial extracorporeal membrane oxygenation

2022

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Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly applied in patients with cardiogenic shock in recent years. Nevertheless, many patients cannot be successfully weaned from VA ECMO support and 1-year mortality remains high. A systematic approach could help to optimize clinical management in favor of weaning by identifying important factors in individual patients. Here, we provide an overview of pivotal factors that potentially prevent successful weaning of VA ECMO. We present this through a rigorous approach following the relatable acronym ABCDE, in order to facilitate widespread use in daily practice.

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“…Indeed, frequent arrhythmias [mainly atrial fibrillation (AF)] can ultimately lead to arrhythmia-induced cardiomyopathy and refractory CS ( 20 ). Reports on arrhythmia-induced CS are scarce and probably underrecognized, but Hékimian et al reported that CS was the first disease manifestation in 60% of their non-ischemic VA ECMO population with recent onset of supraventricular arrhythmia ( 21 ).…”

Section: Percutaneous Mcs Support During Arrhythmia-related Cardiogen...mentioning

confidence: 99%

Mechanical circulatory support in ventricular arrhythmias

Tavazzi

Dammassa

Colombo

et al. 2022

Front. Cardiovasc. Med.

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In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.

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Arrhythmia-induced cardiomyopathy: A potentially reversible cause of refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation

Cited by 17 publications

References 24 publications

Cardiogenic shock with highly complicated course after influenza A virus infection treated with vva-ECMO and Impella CP (ECMELLA): a case report

Cardiogenic shock with highly complicated course after influenza A virus infection treated with vva-ECMO and Impella CP (ECMELLA): a case report

The ABCDE approach to difficult weaning from venoarterial extracorporeal membrane oxygenation

Mechanical circulatory support in ventricular arrhythmias

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