The use of percutaneous ECMO support as a ‘bridge to bridge’ in heart failure patients: a case report

Abstract

A 65-year-old male with a known history of ischemic cardiomyopathy was admitted to the intensive care unit in cardiogenic shock. Cardiac catheterization revealed bi-ventricular hypokinesis, with an estimated ejection fraction of 15%. Despite moderate inotropic support, the patient's liver enzymes, international normalization ratio (INR), and creatinine became grossly elevated, indicating multi-organ injury from hypoperfusion. Due to the patient's state of shock and probable bleeding complications, a full sternotomy and emergent biventricular assist device insertion was deemed very high risk. In order to achieve hemodynamic stability, a decision was made for extracorporeal membrane oxygenation (ECMO) support. ECMO support was quickly initiated by percutaneous cannulation of the femoral vein and artery. The ECMO circuit was comprised of a Centrimag blood pump and Quadrox-D Safeline-coated membrane oxygenator. With successful perfusion and organ resuscitation, abnormal liver function tests, INR, and creatinine all returned to normal in less than one week. With normal organ function, especially the liver, the patient successfully underwent an implantable left ventricular assist device, HeartMate II LVAD, without requiring mechanical right heart support. Prior to ECMO, the patient was at very high risk of needing biventricular support. Thus, the temporary use of ECMO allowed for a safer and more durable bridge to transplantation. The use of percutaneous ECMO has many advantages, including improving the patient condition and allowing for time to evaluate fully the LVAD patient.

Pharmacokinetic changes in patients receiving extracorporeal membrane oxygenation

“…It is usually used as a bridge to recovery but can also be used as a bridge to long-term mechanical assist devices or heart and/or lung transplantation [3][4][5][6]. Clinically, ECMO is a temporizing measure that can facilitate planning of definitive treatment, optimization of patient physiology, and organ perfusion while the underlying pathology is being assessed and treated [1].…”

Increased Sedation Requirements in Patients Receiving Extracorporeal Membrane Oxygenation for Respiratory and Cardiorespiratory Failure

“…Extracorporeal membrane oxygenation (ECMO) temporarily supports patients with severe cardiac and/or respiratory failure that is not responsive to maximal conventional treatment 1 . It is usually a bridge to organ recovery, but can also be used as a bridge to long-term mechanical assist devices or transplantation 2,3 . Its role extends even further as an adjunct to cardiopulmonary resuscitation (CPR) 4 , as well as high risk percutaneous cardiac interventions 5 .…”

Extracorporeal Membrane Oxygenation Applications in Cardiac Critical Care

“…These improvements have also reduced the incidence of hemolysis and decreased the risk of thrombogenic events and tubing rupture. 5,8,9 Finally, contemporary ECMO circuits are heparin coated, which results in reduced platelet activation, reduced complement activation, reduced granulocyte activation, greatly reduced heparin requirements, and an ability to run a circuit without heparinization for brief periods of time. 10…”