Case Reports: Case Report
High-risk percutaneous cardiac interventions, such as percutaneous valvuloplasty or valve implantation and treatment of left main (LM) coronary disease, will probably become commonplace as these technologies continue to evolve. These procedures are being performed on patients who otherwise would not be surgical candidates. Because these procedures and the patients’ comorbidities carry significant risk, the use of circulatory support may be considered. The use of percutaneous ventricular assist devices has been extensively described in the facilitation of high-risk percutaneous coronary intervention (PCI).1–5 More recently, use of extracorporeal membrane oxygenation (ECMO) has been reported for emergent PCI in patients with cardiogenic shock with improved 30-day6 and 1-year7 clinical outcomes. Here, we present an elective case of ECMO-facilitated LM PCI and balloon aortic valvuloplasty (BAV) being performed on a critically ill patient with LM coronary disease, severe aortic stenosis (AS), and ischemic cardiomyopathy, as a bridge to a more definitive surgical correction.
The patient gave his full permission and informed consent for the publication of his case. He was informed of the purpose and educational nature of the case report, and he understood that the case presentation would be free of identifying information.
A 69-year-old man with AS, ischemic cardiomyopathy, coronary artery disease, pulmonary hypertension, end-stage renal disease necessitating hemodialysis, and morbid obesity presented with non-ST elevation myocardial infarction and cardiogenic shock. Cardiac catheterization revealed 70% stenosis of the LM coronary artery as well as diffuses disease of the left anterior descending and obtuse marginal arteries. Transesophageal echocardiography (TEE) revealed severe AS, an aortic valve area of 0.85 cm2 (Fig. 1), severe left ventricular (LV) systolic dysfunction with an LV ejection fraction of 15% to 20%, septal/anterior akinesis, lateral/inferolateral hypokinesis, pulmonary hypertension with pulmonary artery (PA) systolic pressure in the 70 seconds by tricuspid regurgitation jet and grade 3 diastolic dysfunction.
Because of his high surgical risk, the patient was scheduled for LM PCI and BAV supported by ECMO. These palliative procedures were performed not only for symptom relief but also in hopes of recruiting hibernating myocardium and improving LV function, thereby making him a better surgical candidate.
After placement of radial arterial, central venous, and PA catheters in the awake patient, general anesthesia was induced with etomidate (1.5 mg/kg), lidocaine (1 mg/kg), and succinylcholine (1.5 mg/kg). After induction, his systolic blood pressure decreased from the range of 90 to the range of 60 mm Hg, necessitating support with epinephrine and vasopressin drips. Anesthesia was maintained with oxygen, isoflurane, and rocuronium. Inhaled nitric oxide was used at 40 ppm throughout the procedure. The PA pressures were 65 to 70 mm Hg, the mixed venous oxyhemoglobin saturation (SvO2) was 50% to 55%, and the cardiac index was approximately 1.2 L/min/m2.
Left femoral venoarterial ECMO was initiated and maintained by the cardiothoracic surgery service. Argatroban was used for anticoagulation, since the patient had a history of heparin-induced thrombocytopenia. Degree of anticoagulation with argatroban was monitored with serial activated clotting time and activated partial thromboplastin time. After initiation of ECMO, the SvO2 increased from 53% to 83%. Vasopressin was discontinued, and epinephrine was decreased to a much lower rate. The patient received l50 mcg fentanyl and 2 mg midazolam.
The cardiothoracic surgery team remained immediately available while the cardiologist performed the interventions. First, the LM PCI was completed. During inflation of the angioplasty balloon, TEE examination revealed that the LV function became markedly impaired, but ECMO support kept the patient’s SvO2 and mean arterial blood pressure stable (Fig. 2). The BAV was performed next, resulting in an increase in the aortic valve area to 1.46 cm2 (Fig. 3), with only trace aortic insufficiency noted. Due to the presence of full ECMO support, rapid ventricular pacing was not used during BAV. Catheter access sites were closed with the perclose sutures. No blood products were needed because blood loss was minimal during the procedure.
At the conclusion of the procedure, the patient’s trachea remained intubated during ECMO support overnight in the cardiothoracic surgical intensive care unit. He was sedated with propofol and fentanyl infusions. Inhaled nitric oxide was discontinued, while low-dose epinephrine was continued in the intensive care unit. The next day, the patient underwent uneventful ECMO decannulation. Follow-up TEE showed stable AVA of 1.3 cm2 and improvement in LV function, with mobilization of the akinetic segments. The remainder of his postoperative course was uneventful, and he was discharged on postintervention day #7.
Over the ensuing 6 months, the patient’s exercise tolerance improved, and repeat echocardiography revealed that LV ejection fraction had increased to 30% to 40%. Because of his improved condition, he was deemed a good surgical candidate. The patient underwent aortic valve replacement, as well as coronary artery bypass grafting (left internal mammary artery to left anterior descending, saphenous vein to obtuse marginal, and saphenous vein to left posterior descending artery). He had an uneventful postoperative course and was discharged on postoperative day #13.
As percutaneous cardiac interventions continue to evolve, especially in the field of transcatheter aortic valve interventions and coronary angioplasty for complex lesions, high-risk procedures performed on patients deemed too ill for surgery may become more common. What were once considered lower-risk procedures compared with open cardiac interventions may no longer be so, because of complex comorbidities in the patients and the increasingly complex nature of the interventions.
BAV requires balloon inflation in and occlusion of the aortic root, which halts all coronary perfusion and systemic cardiac output and raises LV afterload, leading to myocardial ischemia and possible circulatory collapse. LM PCI also carries risk, because it requires angioplasty balloon inflation in the LM coronary artery, that stops all left-sided coronary blood flow. These ischemia-inducing activities are likely to be poorly tolerated in patients with marginal physiologic reserve. As with our patient, angioplasty balloon inflation is associated with depression in cardiac pulsatility and LV function.8
Others have described the use of percutaneous LV assist devices like the TandemHeart (Cardiac Assist Inc., Pittsburg PA)1–4 and the Impella Recover (Abiomed, Danvers MA)5 that are used to facilitate high-risk PCI. TandemHeart requires transseptal puncture that complicates its placement. With Impella Recover, the arrhythmogenic effect of the rotary blood pump due to LV stimulation is a serious concern, especially in the patient with poor cardiac function. We believed that ECMO would be better suited for our patient because of his severe pulmonary hypertension and the high risk of acute intraoperative right ventricular failure.
Although the use of ECMO to support emergent PCI in critically ill patients is feasible and well documented,6,7,9 any benefits compared with percutaneous ventricular assist devices in prospective, randomized trials have not been documented. It is also unclear whether the use of ECMO would be beneficial in elective situations or in urgent, but not emergent, situations. ECMO use requires expertise in surgical placement, as well as maintenance of the technology, with particular attention to therapeutic anticoagulation. It should be performed only in centers with appropriate surgical backup available for vascular complications from large cannulas. Furthermore, it is our opinion that the technique of BAV should be performed only in centers with appropriate cardiac surgical backup available for complications of this procedure, including severe aortic insufficiency or annular rupture from balloon inflation.
This case highlights a potentially important role for the elective use of ECMO to facilitate high-risk percutaneous cardiac interventions in patients who would otherwise not tolerate the associated hemodynamic challenges. It is likely that use of this hybrid approach to perform palliative percutaneous cardiac interventions that improved cardiac function ultimately enabled our patient to undergo a more definitive surgical intervention, with subsequent improvement in quality of life. The safety and efficacy of this treatment needs to be evaluated in future trials.
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© 2014 International Anesthesia Research Society
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