Author + information
- Received March 29, 2017
- Accepted April 6, 2017
- Published online July 17, 2017.
- Corstiaan A. den Uil, MD, PhDa,b,∗ (, )
- Dinis dos Reis Miranda, MD, PhDb,
- Nicolas M. Van Mieghem, MD, PhDa and
- Lucia S. Jewbali, MDa,b
- aThoraxcenter, Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
- bDepartment of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
- ↵∗Address for correspondence:
Dr. Corstiaan A. den Uil, Erasmus Medical Center, Department of Cardiology and Intensive Care Medicine, Room Bd-120, ‘s-Gravendijkwal 230, NL-3015 CE Rotterdam, the Netherlands.
A 50-year-old woman presented with influenza A–associated myocarditis complicated by refractory cardiogenic shock. She was intubated and mechanically ventilated, and received venoarterial extracorporeal membrane oxygenation (ECMO) by femoral cannulation. Vasopressors could then be weaned. ECMO flow was 4 l/min and the aortic valve opened every beat, but there was continuous moderate aortic valve regurgitation and progressive pulmonary edema (Figure 1A). Through a lateral thoracotomy, a surgical vent was then advanced in the left ventricular apex via the right upper pulmonary vein and connected to the ECMO drainage tubing, decompressing the left ventricle with 800 ml/min flow through the vent (Figures 1B and 1C). However, even after lowering total ECMO and vent flow, the aortic valve did not open anymore and there was extensive spontaneous contrast with risk of thrombus formation in the aortic root (Figure 1D). Successive implantation of an intra-aortic balloon pump (IABP) (Figure 1E) and starting 1:1 counterpulsation (Figure 1F) caused the aortic valve to open with every heartbeat (Online Videos 1, 2, and 3 were captured during start, temporary stop, and 1:3 counterpulsation). Aortic valve regurgitation did not increase. Following myocardial recovery, ECMO support was successfully stopped after 10 days and IABP support after 12 days.
There are conflicting data on the benefit of routine left ventricular venting during venoarterial ECMO (1–3). Through real-time echocardiography, this case confirms the usefulness of IABP counterpulsation in maintaining aortic valve opening in this specific pathology (4).
For supplemental videos and their legends, please see the online version of this article.
Dr. Reis Miranda has received speaking fees from Xenios GmBH. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 29, 2017.
- Accepted April 6, 2017.
- 2017 American College of Cardiology Foundation
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