A 53-year-old male with heart failure secondary to ischemic
cardiomyopathy and mitral regurgitation underwent CABG and mitral valve
repair 3 years prior to presentation with improvement in symptoms. He
subsequently developed cardiac arrest requiring dual-chamber ICD
placement. He did well for 6 months, until he presented with increased
edema and decreased functional capacity. Echocardiography revealed an LV
ejection fraction of 15%. Coronary angiography revealed patent bypass
grafts without new focal lesions. Right heart catheterization revealed
elevated filling pressures and a depressed cardiac index. He was started
on intravenous inotropes and an intraaortic balloon pump was placed,
however, his hemodynamic status continued to decline. The decision was
made to increase level of support to VA ECMO as bridge to transplant
(BTT). We decided to use a
Bio-medicus NextGen multi-stage
cannula for left atrial (LA) VA ECMO in order to obtain left-sided
venting and venous drainage simultaneously. Using ultrasound guidance
and a micropuncture technique, a right common femoral arterial access
was obtained and a 6 French sheath was placed. Right femoral angiography
demonstrated a suitable vessel for large-bore access and mapped the
superficial femoral artery (SFA) for placement of the antegrade sheath.
The access to the SFA was then obtained and a 6 French x 24 cm braided
arrow sheath was inserted for antegrade perfusion. The right femoral
venous access was obtained using ultrasound guidance and a micropuncture
technique and a 7 French sheath was placed. The patient was heparinized
to achieve an activated clotting time (ACT) greater than 300 seconds.
Next, an SL-1 sheath and BRK needle were used to perform transseptal
puncture under real-time transesophageal echocardiographic guidance. The
SL-1 sheath was removed and a ProTrack⢠wire (Baylis; Mississauga, ON,
Canada) was advanced into the LA. Next, the atrial septostomy was
performed using a 6 mm x 40 mm peripheral balloon. Then, the venous
tract was serially dilated and a 23 French Bio-medicus NextGen cannula
multistage was inserted with 4 cm of its tip in the LA, leaving the
first set of ports inside of the LA for LV venting, and the second set
of ports in the inferior vena cava (IVC) for venous drainage; followed
with a 17 French arterial cannula placed in the right common femoral
artery and the patient was initiated on LA-VA ECMO. The arterial return
cannula was connected to the antegrade perfusion sheath to provide flow
to the right lower extremity. The patient remained stable after the
procedure, without signs of LV distension and no complications. A
suitable donor was available 3 days later, and he underwent a successful
heart transplantation.