Short-Term Mechanical Circulatory Support: Transitioning the Patient to the Next Stage

Steven S. Qi, Andrew W. Shaffer, Rebecca Cogswell, Ranjit John
2020 JTCVS Open  
Short-term mechanical circulatory support is an important tool for managing cardiogenic shock. 38 The framework for decision-making is critical in deciding the appropriate end goal and 39 progressing care efficiently. 40 41 Clinical Vignette: 42 A 32-year-old male presented to the emergency department with acute cardiogenic shock: mean 43 arterial pressure (MAP) 50 mmHg despite initiation of high dose vasopressors, heart rate 130 44 beats/min, pulse pressure 10 mmHg, and respiratory rate 35
more » ... iratory rate 35 breaths/min. Initial lab values 45 showed elevated transaminases, creatinine 3.7 mg/dL, troponin 23 ng/ml, lactate 10 mg/dl. 46 Bedside echocardiogram showed biventricular ejection fractions of 5-10% with normal left 47 ventricular (LV) dimensions. ECG showed no acute ischemia however frequent runs of 48 ventricular tachycardia were occurring with two shocks required in the emergency department. 49 The patient was transferred to the cardiac catheterization lab, placed on peripheral venoarterial 50 extracorporeal membrane oxygenation (VA ECMO), and intubated. Coronary angiogram was 51 normal and an endomyocardial biopsy was performed. A femoral intraaortic balloon pump was 52 placed for LV unloading. Biopsy returned as myocarditis and Coxsackie titers were consistent 53 with acute infection. Urine toxicology was negative. 54 55 Over the first 3 days of VA ECMO support, the patient went onto continuous renal replacement 56 therapy, liver enzymes downtrended, lactate normalized, and the patient remained 57 neurologically intact. Pulsatility was minimal on the arterial line tracing. On day 4 an ECMO 58 turndown study showed mild to moderate RV dysfunction with LVEF of 10%. On 1 L/min of 59 ECMO support, MAP dropped to 50 mmHg, PCWP to 20 mmHg, and cardiac index (CI) 60 dropped to 1.5. Given failure of turndown study, upper extremity arterial ultrasounds were 61 performed to plan transition to subclavian Impella 5.0. On day 5 the patient was transitioned to 62 Impella 5.0 support and was extubated 2 days later. LVEF remained at 10% with several failures 63 of Impella weaning at week 3 and ultimately a durable LVAD was placed. The patient had 64 recovery of renal function at 1 month post-LVAD and LV function normalized by month 8. 65 Successful explantation of the LVAD was performed at 1 year post LVAD implantation after 66 confirmation of cardiac recovery. 67 68 Introduction 69 Studying the management of cardiogenic shock (CS) in a rigorous way has proven to be difficult. 70 Randomization to a non-device strategy for patients with refractory CS is not possible and so 71 data to develop guidelines must be extrapolated from randomized trials of less sick patients, non-72 randomized trials, and pooled institutional experience. Cardiogenic shock is also complex: there 73 is a spectrum of shock ranging from early end-organ dysfunction to multisystem organ failure 74 with inflammatory cytokine-mediated vasodilation 1 . The etiology can be predominately left-75 sided, right-sided or biventricular, and the syndrome can occur in patients with chronic heart 76 failure or those with normal cardiac function who suffer an acute insult. While the immediate 77 goals of temporary support are to stabilize the patient and restore perfusion, the longer-term goal 78 can vary based on the likelihood of recovery, the severity of myocardial injury, and candidacy 79 for advanced therapies such as cardiac transplantation or left ventricular assist device (LVAD) 80 placement. All of these factors contribute to the complexity and the wide variation in 81 management of these patients. 2 82
doi:10.1016/j.xjon.2020.04.001 fatcat:io5iidsuv5fv7mgsgnjzbedp7a