A 55-year-old man with a history of morbid obesity, uncontrolled diabetes mellitus, and smoking presented to the emergency department 48 hours after the onset of chest pain. He was in cardiogenic shock with sinus tachycardia to 120 beats per minute and hypotension with a blood pressure of 87/55 mm Hg. An electrocardiogram (ECG) showed ST elevations and an emergent cardiac catheterization was performed, which demonstrated an occluded left anterior descending artery. The occlusion could not be crossed with a wire and during the procedure the patient went into ventricular fibrillatory arrest. Immediate cardiopulmonary resuscitation was undertaken and despite numerous rounds of pharmacologic therapy and chest compressions, a perfusing rhythm and pressure were not achieved. He was placed on percutaneous venoarterial extracorporeal membrane oxygenation (VA-ECMO) via the femoral vein and femoral artery for acute cardiogenic shock. Over the next 7 days, he was weaned off of VA-ECMO support and was discharged home on optimal medical therapy for his coronary artery disease (CAD).
VA-ECMO is typically considered in the setting of continued end-organ hypoperfusion, despite escalating doses of inotropic support with or without the use of an intra-aortic balloon pump for augmentation. In such cases of refractory cardiogenic shock, VA-ECMO is used to bridge patients to recovery, surgical intervention, transplantation, or left ventricular assist device (LVAD). The most common indications for VA-ECMO include fulminant myocarditis, post-cardiotomy support, acute myocardial infarction (MI), and post heart transplant for early graft failure (Table 36-1). Other indications include refractory ventricular tachycardia or ventricular fibrillation unresponsive to conventional therapy, hypothermia, acute anaphylaxis, pulmonary embolism, peripartum cardiomyopathy, sepsis-related cardiac depression, and drug overdose.
Table 36-1Indications for VA-ECMO Support ||Download (.pdf) Table 36-1 Indications for VA-ECMO Support
|Post-cardiotomy support |
|Acute fulminant myocarditis |
|Acute myocardial infarction |
|Post heart transplant for early graft failure |
|Refractory ventricular tachycardia or ventricular fibrillation unresponsive to conventional therapy |
|Acute anaphylaxis |
|Pulmonary embolism |
|Peripartum cardiomyopathy |
|Sepsis-related cardiac depression |
|Drug overdose |
There is no standardized and universally accepted list of contraindications to VA-ECMO. Nonetheless, there are several contraindications that we believe many groups would agree upon (Table 36-2). These include advanced age (>75-80 years), active malignancy with an expected survival of less than 1 year, severe peripheral vascular disease, end-stage renal disease on dialysis, advanced liver disease, current intracranial hemorrhage or other contraindication to systemic anticoagulation, unwitnessed cardiopulmonary arrest with ongoing cardiopulmonary resuscitation, and witnessed cardiopulmonary arrest with prolonged cardiopulmonary resuscitation (>30 minutes) without return of spontaneous circulation.
Table 36-2Contraindications to VA-ECMO Support ||Download (.pdf) Table 36-2 Contraindications to VA-ECMO Support
|Age >75-80 y |
|Active malignancy with expected survival <1 y |
|Severe peripheral vascular disease |
|End-stage renal disease on dialysis |
|Advanced liver disease |
|Current intracranial hemorrhage or other contraindication to systemic anticoagulation |
|Unwitnessed cardiopulmonary arrest ...|