A Mini-Thoracotomy Approach for Walking Veno-Arterial Extracorporeal
Membranous Oxygenation
Abstract
Fulminant myocarditis is a rapidly progressive myocardial inflammation
that commonly requires advanced therapies circulatory support. We report
our management for a case of fulminant myocarditis and cardiogenic
shock. The patient is a 36 year old gentleman who was admitted after a
one week history of malaise. Upon admission he was lethargic with
jugular venous distension to 10 cm. He was taken immediately for a heart
catheterization and intra-aortic balloon pump placement. There was no
obstructive coronary disease, and hemodynamics were consistent with
biventricular failure. After multidisciplinary evaluation, we elected to
proceed with emergent extracorporeal membranous oxygenation (ECMO). We
utilize a Protek Duo Rapid Deployment (LivaNova, Mirandola, Italy) which
is inserted via modified Seldinger technique through the left
ventricular apex, terminating in the ascending aorta. Percutaneous right
IJ bicaval via a y-ed Avalon Elite (Getinge, Goteborg, Sweden) approach
is employed for venous drainage (Figure 1). We believe that with this
alternative ECMO cannulation platform, we address the multitude of
drawbacks that plague peripherally cannulated extracorporeal circulatory
support, minimizing patient deconditioning and upper/lower extremity
over/under perfusion complications, while providing sternal sparring
antegrade arterial flow with ventricular unloading/venting. For two
weeks the patient was ambulatory, but because we were unable to obtain
an adequate offer during this interval, we transitioned to a bridge to
bridge therapy. This case highlights an alternate strategy for central
walking VA ECMO in the rare presentation of one patient’s progression
from IABP to VA ECMO to durable BiVAD to heart transplantation during a
single admission.