Combined pulmonary and left ventricular support with veno-pulmonary ECMO and impella 5.0 for cardiogenic shock after coronary surgery

Abstract

BackgroundMechanical circulatory support is a common practice nowadays in the management of patients after cardiogenic shock due to myocardial infarction. The single or combined use of one or more devices for mechanical support depends not only on the advantage or disadvantage of these devices but also on the timing of use of these devices before the development of multi organ failure. In our case we used more than one tool for mechanical circulatory support during the prolonged and complicated course of our patient with postcardiotomy cardiogenic shock after coronary artery bypass surgery.Case PresentationWe describe the combined use of Impella 5.0 and veno- pulmonary extra corporeal membrane oxygenation (VP-ECMO) for biventricular failure in a 52 years—old man. He presented with cardiogenic shock after inferior wall ST-elevation myocardial infarction. After emergency coronary artery bypass surgery and failure to wean from extracorporeal circulation we employed V-P ECMO and consecutively Impella 5.0 to manage the primarily failing right and secondarily failing left ventricles.He remained hemodynamically stable on both Impella 5.0 and VP-ECMO until Heart Mate II left ventricular assist device implantation on the 14th postoperative day. Right sided support was weaned on 66th postoperative day. The patient remained in the intensive care unit for 77 days. During his prolonged stay, he underwent renal replacement therapy and tracheostomy with complete recovery. Six months later, he was successfully heart transplanted and has completed three and half years of unremarkable follow up.ConclusionsThe combined use of VP ECMO and Impella 5.0 is effective in the management of postcardiotomy biventricular failure as a bridge for further mechanical support or heart transplantation.

Percutaneous Pulmonary Artery Cannulation to Treat Acute Secondary Right Heart Failure While on Veno-venous Extracorporeal Membrane Oxygenation

“…Using similar techniques, however, prior studies have demonstrated the efficacy and safety of using surgically-implanted PA outflow cannulas in-line with ECMO circuits to provide RV and respiratory support with flows up to 5 L/min more than 7-185 days. [16][17][18][19][20][21][22] Of the percutaneous devices on the market, the Impella RP cannot provide oxygenation support, whereas the Protek Duo cannula can be used with an in-line oxygenator. 5 The use of the Protek Duo cannula for combined RHF and respiratory failure primarily has been described in case reports with few larger series, as demonstrated in Table 3.…”

“…Using similar techniques, however, prior studies have demonstrated the efficacy and safety of using surgically-implanted PA outflow cannulas in-line with ECMO circuits to provide RV and respiratory support with flows up to 5 L/min more than 7–185 days. 16–22…”

Hybrid extracorporeal membrane oxygenation

“…Also, Eliet et al showed that Impella could improve pulmonary flow and ensure effective LV discharge during VA ECMO therapy (43). The Impella device has been also associated with VPa cannulation to provide effective biventricular support in case of severe cardiogenic shock (44). Finally, Impella implantation during VA ECMO is as effective as surgical LV venting to promote ventricular and pulmonary unloading, with similar outcome and complications (45).…”