Venoarterial extracorporeal membrane oxygenation as a bridge to surgery in ischemic papillary muscle rupture

The prognosis of papillary muscle rupture (PMR) leading to acute mitral regurgitation and cardiogenic shock remains dismal, with survival dependent on prompt recognition and surgical intervention [1]. Papillary muscle rupture surgical repair is one of the higher-risk operations done in cardiac surgery and its outcome is poor in the presence of decreased cardiac output, hepato-renal failure and metabolic acidosis [2].
The acute hemodynamic consequences of PMR lead to rapidly progressive acute respiratory failure and severe cardiogenic shock, often refractory to conventional management, such as mechanical ventilation, inotropic support treatment and intra-aortic balloon pump (IABP) [3]. The ideal time of surgery for these patients remains unclear, and in fact a significant portion of these patients are considered too risky for immediate operative stress due to multi-organ failure (MOF).
Mortality without surgery reaches 80%, and operative mortality within 30 days of surgery ranges from 20% to 40% [4].
Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) provides circulatory and/or respiratory support and immediate hemodynamic stabilization in these critically ill patients, and can be used as a bridge to surgery.
We present 2 cases of refractory cardiogenic shock due to PMR successfully supported with VA-ECMO initiated before surgical intervention.
Case series: Patient 1. A 50-year-old male patient was admitted to a peripheral hospital due to posterior wall myocardial infarction. He underwent an emergency coronary angiography and percutaneous coronary intervention (PCI) to the left circumflex (LCX) and right coronary artery (RCA) with drug-eluting stents. Transthoracic echocardiography revealed severe mitral valve regurgitation due to posteromedial PMR. Owing to refractory cardiogenic shock despite maximal conventional treatment (mechanical ventilation, inotropic support), the patient was transferred to our institute for further treatment. Upon arrival at the intensive care unit, blood pressure was 100/60 mm Hg, heart rate 150 bpm, lactate level was 4.9 mmol/l, and peripheral VA-ECMO (femoral artery cannula 17F, femoral vein cannula 22F) for hemodynamic support and clinical stabilization was initiated. Within VA-ECMO support, clinical stabilization (drop of lactate to 1.3 mmol/l) allowed cardiac surgery to be performed 4 days later, consisting in mitral valve replacement (MVR) with an ATS 27 mm mechanical valve...


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