(222) VA ECMO for Protected PCI in Cardiac Arrest due to Refractory Polymorphic Ventricular Tachycardia

Introduction: The role of venoarterial extracorporeal membrane oxygenation (V-A ECMO) has been well established in cardiogenic shock (CS). The application of percutaneous coronary intervention (PCI) to an increasingly complex patient population has compelled the more frequent use of mechanical circulatory support (MCS) for left ventricular unloading and hemodynamic support during high-risk procedures. In these patients, V-A ECMO is an excellent option to provide full cardiopulmonary support along with continued perfusion of the microcirculation and reduction in requirements for inotropes and vasopressors during protected PCI.

Description: A 59-year-old man with coronary artery disease (CAD), non-ST-elevation myocardial infarction, and ischemic cardiomyopathy was being evaluated for coronary artery bypass graft secondary to high-grade multi-vessel CAD. The patient developed recurrent episodes of polymorphic ventricular tachycardia (PVT) requiring multiple rounds of advanced cardiac life support and defibrillating shocks. Return of spontaneous circulation following defibrillations (200 Joule each), could be achieved seven times. Due to the refractory nature of the arrhythmia, the decision was made to cannulate the patient for V-A ECMO to provide adequate perfusion for the patient. Intra-aortic balloon pump and temporary percutaneous left ventricular assist devices were not likely to be adequate support for patients with refractory arrhythmia cardiac arrests and CS. This decision was made at the bedside after a multi-disciplinary discussion between the anesthesiology critical care medicine team and the cardiothoracic surgery team. With perfusion established, the vasopressor requirements could be significantly reduced, and the patient was transferred to the cardiac catheterization laboratory for PCI. With improved myocardial perfusion, the patient was successfully weaned from V-A ECMO support and was decannulated after 48 hours. He left the intensive care unit 6 days later without any further arrhythmic episodes.

Discussion: Protected PCI is becoming more common with the increase in high-risk PCI. V-A ECMO is an important option to consider in cases with severe CS. Our case shows the feasibility of utilizing V-A ECMO in CS secondary to refractory PVT for protected PCI.