Royal Brompton & Harefield NHS Foundation Trust, Critical Care and Anaesthesia, Harefield, United Kingdom Wepresent a case of a 22 years old man who was admitted to our tertiary referral centre for consideration of Biventricular Ventricular Assist Device (BIVAD) insertion vs. transplant assessment. He had no significant medical history, and was initially admitted in August with signs and symptoms of congestive heart failure. A DCM (dilated cardiomyopathy) of uncertain cause was diagnosed. Cardiac MRI (Magnetic Resonance Imaging) did not show any late gadolinium enhancement; left ventricular ejection fraction (LV EF) 12%. He was stabilised with optimal medical therapy, and discharged home weeks later. The patient was readmitted 3 weeks later with worsening heart failure, acute kidney injury, and presumed-hypoxic hepatitis. Despite maximal medical therapy and IABP (Intra Aortic Balloon Pump) the patient remained in profound cardiogenic shock. Peripheral VA ECMO (Veno Arterial Extracorporeal Membrane Oxygenation) was inserted and the patient was transferred to our centre. Soon after arrival patient lost pulsatility, had a drop in ETCO2 (End Tidal CO2) and a rising CVP (Central Venous Pressure). Bedside transthoracic echocardiography TTE (see images) confirmed absence of LV ejection and the aortic valve was closed. LV dilatation had increased, was ballooning and filled with spontaneous echocontrast. Patient who lost pulsatility and responded initially to inotropric support, lost pulsatily again. Because it was thought that a reduction in afterload could facilitate LV ejection, we decided to bolus GTN. This had an immediate response of increased MAP (Mean Arterial Pressure), reduced CVP, increased ETCO2, and evidence of restoration of LV ejection. This case reflects the complexity of the hemodynamic management of patients undergoing peripheral ECMO. In some cases reducing the afterload would be the best strategy to achieve LV ejection. Parasternal long axis. AV closed.
Publication information
A Fort, C Hernandez , A Hurtado, T Tsoutsouras, F Caetano, M Desai, J Mitchell, D Hall, C Morgan, J Farrimon. GTN to increase pulsatilty in a patient with VA ECMO for refractory cardiogenic shock. European Journal of Heart Failure (2015) 17 (Suppl. 1): 146.