Successful weaning from veno-arterial ECMO and Impella2.5 by veno-venous and arterial ECMO (v-ECPELLA) for a patient with acute myocardial infarction complicated by severe lung injury

Open ArchivePublished:May 27, 2020DOI:https://doi.org/10.1016/j.jccase.2020.05.004

      Abstract

      The Impella™ (Abiomed, Danvers, MA, USA) is a percutaneous left ventricular assist device and is concurrently used with veno-arterial extracorporeal membrane oxygenation (VA ECMO). However, concomitantly using these two devices makes identifying the mixed zone of two opposite blood flows difficult. We report the case of an 80-year-old man with ST-elevation myocardial infarction and cardiopulmonary arrest. Emergent coronary angiography showed 99% stenosis in the left main trunk. A drug-eluting stent was placed under support of VA ECMO and the Impella2.5 for cardiogenic shock. During this support, antegrade deoxygenated blood enhanced by the Impella was sent to the right radial artery. Inadequate oxygenated blood was delivered through the native lung, which was damaged by cardiopulmonary resuscitation. We decided to convert to veno-venous and arterial ECMO (V-VA ECMO) using additional venous cannulation as drainage. Returned oxygenated blood was sent to the inferior vena cava and femoral artery bilaterally for maintaining oxygenation in the pulmonary artery. In V-VA ECMO and the Impella (v-ECPELLA), we attempted weaning from VA ECMO by only clamping VA cannulation and switching to veno-venous ECMO. We restored the setting to VA ECMO after assessment of the systemic circulation. We successfully managed and weaned our patient from simultaneous use of VA ECMO and the Impella2.5 by using v-ECPELLA.
      <Learning objective: Simultaneous use of the Impella and veno-arterial extracorporeal membrane oxygenation (VA ECMO) is sometimes required in cases with severe lung injury. However, using these two devices may increase unexpected perfusion of unoxygenated blood in the coronary and cerebral arts. Veno-venous and arterial ECMO with the Impella can reduce the risk of hypoxia because of returned oxygenated blood to the inferior vena cava. This method might be useful for maintaining and weaning from simultaneous use of VA ECMO and the Impella.>

      Keywords

      Introduction

      The Impella™ (Abiomed, Danvers, MA, USA) is a temporary left ventricular assist device that is expected to have better efficiency for cardiac shock compared with intra-aortic balloon pumping (IABP) [
      • Basir M.B.
      • Schreiber T.L.
      • Grines C.L.
      • Dixon S.R.
      • Moses J.W.
      • Maini B.S.
      • et al.
      Effect of early initiation of mechanical circulatory support on survival in cardiogenic shock.
      ]. Occasionally, simultaneous use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) and the Impella (called EC-PELLA) is required in cases with severe lung injury. However, using these two devices in conjunction may increase unexpected perfusion of unoxygenated blood suctioned from the left ventricle into the ascending aorta assisted by the Impella. Particularly in cases with a lack of improvement in lung function, maintaining EC-PELLA and weaning from VA ECMO are exposed to the risk of oxygen desaturation at the coronary and cerebral arteries. Control of sufficient blood oxygenation in the ascending aorta and maintaining the systemic circulation are simultaneously required in patients with lung injury during support by EC-PELLA.

      Case report

      An 80-year-old man had sudden onset of chest pain. The patient’s arterial blood pressure was <80 mmHg, with peripheral circulatory failure and peripheral coldness. The blood pressure was difficult to measure accurately because of the low pressure and sinus tachycardia. The lactate level was 2.4 mmol/L at admission. An electrocardiogram showed a sinus rhythm, elevated ST segment in aVR, non-specific STT change in V4–6. A transthoracic echocardiogram showed diffuse severe left ventricular dysfunction, which was estimated as <20% at admission, without valvular disease. Coronary angiography was immediately performed for diagnosis of ST-elevation myocardial infarction and showed 99% stenosis in the distal side of the left main trunk (Fig. 1A). Percutaneous coronary intervention was performed consecutively via the right radial artery. A Synergy™ stent (Boston Scientific, Marlborough, MA, USA) was implanted in the left main trunk toward the left anterior descending artery and thrombolysis in myocardial infarction grade 3 flow was obtained. Initially, we decided to use the Impella2.5 for cardiogenic shock before starting percutaneous coronary intervention (PCI). We then needed to use additional VA ECMO for ventricular arrhythmia and cardiopulmonary resuscitation during PCI. The left femoral vein and right femoral artery were cannulated and the CAPIOX SL Pump™ (SL pump; Terumo Corporation, Tokyo, Japan) was selected as a membrane. The Impella2.5 was inserted from the right femoral artery.
      Fig. 1
      Fig. 1(A) Left main branch disease in coronary angiography. (B) Drainage cannulation was deployed at the SVC and returned to the IVC. (C) X-ray shows severe pulmonary edema and a linear artifact caused by interference from the IMPELLA. (D) Additional 22F cannulation was used for drainage in the SVC and returned blood was separated by two Y-branched cannulations.
      LMT, left main trunk; LAD, left anterior descending branch; LCX, left circumflex branch; SVC, superior vena cava; IVC, inferior vena cava; VA ECMO, veno-arterial extracorporeal membrane oxygenation; V-VA ECMO, veno-venous and arterial ECMO.
      In the intensive care unit, severe myocardial damage was observed in the patient’s left ventricle. Laboratory data showed high creatine kinase (19,428 IU/L) levels. The setting of the Impella2.5 was initially kept at P8, but systemic mean aortic blood pressure rose higher than 100 mmHg after addition of VA ECMO. The setting was adjusted to <100 mmHg of systemic mean arterial blood pressure because of the risk of cerebral bleeding. In contrast to the steadiness of circulation supported by the Impella2.5, deoxygenation rapidly appeared in his right radial artery during weaning with VA ECMO. Therefore, we needed to restore the setting of continuous support by VA ECMO for lung dysfunction. Initially, support by the Impella2.5 was downgraded from P8 to P4 for avoiding perfusion of deoxygenated blood to the cerebral artery, and continual unloading of his left ventricle was maintained. VA ECMO flow was then adjusted in accordance with the systemic mean aortic blood pressure. As a result, perfusion to the cerebral artery depended on oxygenated blood by VA ECMO. There was a risk of desaturation in the coronary artery in these mechanical support devices.
      Two days after implanting the Impella2.5, we also failed to wean from VA ECMO again. PO2 varied in the right radial artery, despite the fixed setting of the assist devices and respirator. The reason for desaturation in this patient was thought to be congestion caused by severe heart failure. The existence of blood-stained sputum and fracture of the ribs caused by cardiopulmonary resuscitation might be proof of pulmonary injury, but we could not perform additional invasive examinations to determine the pathophysiology in his critical condition.
      Because suctioning whole blood returned from the superior vena cava (SVC) and inferior vena cava (IVC) to the right atrium by ECMO cannulation is impossible, a small amount of desaturated blood escaped from ECMO suction through the right atrium and right ventricle in our patient. Desaturation in the left ventricle leads to a risk of insufficient oxygenation in the coronary and cerebral arteries (Fig. 2B).
      Fig. 2
      Fig. 2Schema of VA ECMO and the IMPELLA.
      (A) VA ECMO: the area of the mixed zone is defined by cardiac output and returned blood pressure. (B) IMPELLA with VA ECMO: blood is drained from the right atrium via the femoral vein and returned to the femoral artery. Flow in the IMPELLA may increase the risk of desaturation in the coronary artery. (C) IMPELLA with V-VA ECMO: oxygenated blood is returned to the IVC and femoral artery simultaneously. Antegrade flow supported by the IMPELLA includes sufficient oxygenated blood.
      ECMO, extracorporeal membrane oxygenation; VA, veno-arterial; V-VA, veno-venous and arterial; IVC, inferior vena cava.
      An additional two cannulations for veno-venous ECMO (VV ECMO) to increase the level of blood oxygenation in the pulmonary artery could reduce the risk of unexpected deoxygenation. However, no venous access site remained, except for the left femoral vein. Therefore, we planned to drain venous blood from the SVC by a 22F quick draw™ catheter (Edwards Lifesciences, Irvine, CA, USA) in addition to the left femoral vein. We also planned to return oxygenated blood to the left femoral artery by 16F cannulation using VA ECMO and this should send blood sequentially to the IVC by an 18F catheter initially used as a drainage catheter of VA ECMO. These two cannulations for sending oxygenated blood were connected by using a Y-branch line and this was called V-VA ECMO (Fig. 1B, C, D). Under sufficient oxygenation in antegrade aortic flow, we maintained the systemic circulation and sufficient oxygenation in the coronary and cerebral arteries. We named this system V-VA ECMO and Impella2.5 (v-ECPELLA) (Fig. 2C). We attempted to wean VA ECMO by clamping arterial cannulation, which leads to VV ECMO. Temporary clamping of femoral artery cannulation easily converted V-VA ECMO to VV ECMO, and then the systemic circulation was kept sufficiently stable to maintain blood pressure by Impella2.5 support. We called this procedure the “temporary VA ECMO off test” (Fig. 3). For preventing thrombus at the area of clamping cannulation, we maintained minimum flow by partial clamping and regularly released the clamp.
      Fig. 3
      Fig. 3Process of mechanical support and arterial blood oxygenation. Weaning from V-VA ECMO and switching to VV ECMO was performed by clamping only VA cannulation for a temporary period. This method can temporarily return the condition of ECMO and the capacity of safe respiratory function can be verified.
      v-ECPELLA, veno-venous and arterial extracorporeal membrane oxygenation with the IMPELLATM; ECMO, extracorporeal membrane oxygenation; VA, veno-arterial.
      Initially, mean aortic blood pressure was >80 mmHg and the amount of urine gradually decreased during the first “temporary VA off test” trial. Under-perfusion of principal organs was suspected when only using the Impella2.5. Therefore, we stopped the trial and returned to V-VA ECMO by releasing only the VA clamp. Additional therapy included diuretic agents, starting with torvaptan, and low doses of a catecholamine agonist. We attempted weaning from VA ECMO. During the next attempt for weaning of VA ECMO, stable vital signs and a sufficient amount of urine were confirmed under the setting of P7 in the Impella2.5 and VV ECMO only. After 24 h of taking a wait-and-see approach under the same setting by monitoring mean aortic and pulmonary artery pressure, the amount of urine, and oxygenation of arterial blood gases in the right radial artery, weaning of VV ECMO was started for the next phase. We successfully weaned off from VV ECMO and V-VA ECMO was accomplished by paying attention to oxygenation under the stability of systemic blood pressure supported by the Impella2.5. On day 9, the Impella2.5 was removed and medical therapy with 0.12 μg/kg/min of noradrenaline, 5.0 μg/kg/min of dobutamine, and 0.50 μg/kg/min of milrinone was performed. The ejection fraction was impaired by approximately 30% after weaning from ECMO and the Impella2.5. After 14 days, extubation was performed and the respirator was turned off after lung injury was fully healed. The patient was admitted to the intensive care unit at 21 days.

      Discussion

      Concurrent use of the Impella2.5 with VA ECMO (EC-PELLA) is useful for patients who have severe lung injury, right-sided heart failure, and repeatable ventricular arrhythmia. In patients with severe lung injury, anterograde flow suctioned from the left ventricle into the ascending aorta by the Impella2.5 includes unoxygenated blood because of inadequate oxygenation in the patient’s lung. Because the mixed zone, which has opposite directional blood currents assisted by VA ECMO and the Impella2.5, is constantly changing and uncontrollable, identifying the origin supplying blood to the ascending aorta is difficult. Therefore, there is a higher risk of unexpected perfusion of unoxygenated blood in the coronary and cerebral arteries during weaning from VA ECMO in patients who have poor lung function. In paticular, patients who have cardiopulmonary resuscitation for cardiopulmonary arrest before admission often have comorbid severe lung dysfunction caused by serious pulmonary edema, perioral effusion, acute respiratory distress syndrome, and traumatic pneumohemothorax caused by cardiopulmonary resuscitation [
      • Miller A.C.
      • Rosati S.F.
      • Suffredini A.F.
      • Schrump D.S.
      A systematic review and pooled analysis of CPR-associated cardiovascular and thoracic injuries.
      ]. Sato et al. reported the efficiency of V-VA ECMO for cardiorespiratory failure [
      • Sato A.
      • Isoda K.
      • Gatate Y.
      • Akita K.
      • Daida H.
      Successful management of a patient with refractory ventricular fibrillation (VF) due to acute myocardial infarction (AMI) and lung injury by transition from percutaneous cardiopulmonary support (PCPS) to veno-venous extracorporeal membrane oxygenation (ECMO).
      ]. Because measurement of oxygen saturation in the ascending aorta and coronary artery is difficult, maintaining sufficient oxygen saturation in the pulmonary artery and left ventricle may be a solution for managing patients with severe lung injury supported by EC-PELLA.
      The procedure of temporary weaning by V-VA ECMO might be a method for maintaining and weaning from simultaneous use of VA ECMO and the Impella2.5. Furthermore, repeatable weaning from VA ECMO alone and restoring the setting from VA ECMO to V-VA ECMO if there is unsatisfactory perfusion by only the Impella2.5 are possible.

      Conflicts of interest

      None.

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