Rescue extracorporeal membrane oxygenation for refractory cardiogenic shock

Introduction

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used for bridge-to-recovery, bridge-to-decision or bridge to ventricular assist device (VAD) implantation or heart transplantation in patients with cardiogenic shock (CS).
We report a case of iatrogenic left main coronary artery (LMCA) dissection and secondary cardiogenic shock in which mechanical cardiopulmonary support with portable ECMO was used to rescue the patient after urgent surgical revascularization. Extracorporeal membrane oxygenation has the potential to improve tissue perfusion without the adverse consequences of medical therapies, consisting primarily of inotropic agents and vasopressors, such as increased myocardial oxygen demand and ischemia, arrhythmogenicity and reduction of tissue microcirculation, creating the opportunity to reduce the high mortality rates currently associated with conventionally managed patients in CS.

Case report

A 59-year-old male patient was admitted to coronary angiography for recurrent chest pain for 1 day. Based on ECG and elevated troponin T, acute coronary syndrome without ST elevation was diagnosed. He had no significant past medical history. Using the right radial approach and a Judkins diagnostic catheter, the very short LMCA was visualized with almost independent take-off of the left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX). First selective contrast injection into the LCX did not show any significant lesions. In order to selectively engage the LAD, excessively deep catheter intubation was performed, which caused iatrogenic LMCA dissection, propagating to the LAD and proximal LCX. Acute LAD closure and contrast extravasation was visualized (Figure 1). Immediate, percutaneous attempts to open the LAD were undertaken. However, despite support with inflated 1.25 mm and 2.0 mm balloons, it was impossible to insert any of the different guidewires into the true lumen of the LAD or diagonal branch. Thus no contrast flow in the mid/distal LAD segments was restored. The patient developed CS, requiring continuous infusion of inotropes, intubation and mechanical ventilation. Thus, he was immediately transferred to a tertiary hospital with the department of cardiac surgery, where rescue off-pump coronary artery bypass grafting (CABG) was performed just a few hours after dissection. Entering the operating room the patient had a sinus rhythm with a heart...


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