(1133) Acute Chest Syndrome and Severe Biventricular Failure: Role of VA ECMO

Introduction: Biventricular failure (BV) is a rare and life-threatening complication of acute chest pain syndrome (ACS). Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) provides circulatory by bypassing the failing ventricles, but its role in ACS is yet to be explored.

Description: A 21-year-old male with sickle cell disease (SCD) was admitted to the intensive care unit for ACS complicated by respiratory failure and cardiogenic shock (day 1). Echocardiogram showed left ventricle ejection fraction of 20% with global hypokinesis and severely reduced right ventricular systolic function. Right heart catheterization (RHC) showed mean pulmonary artery pressure (mPAP) of 32mmHg, pulmonary capillary wedge pressure of 15mmHg, cardiac output (CO) of 2.3 L/min and pulmonary vascular resistance (PVR) of 7.3 wood units (WU), consistent with pre-capillary pulmonary hypertension with high-risk features. He was started on bumetanide drip, norepinephrine, vasopressin, dobutamine infusion, and inhaled epoprostenol. The patient remained hemodynamically unstable with up trending serum lactate. Simple and exchange transfusions were initiated but later held due to lack of clinical improvement and concern for circulatory overload. The patient was cannulated for VA-ECMO and started on renal replacement therapy on day 3. Repeat RHC 48 hours later showed mPAP 25mmHg, PVR 1.6 WU, and CO 10.6 l/m, allowing de-escalation of medical therapy. The hospital course was complicated by left lower extremity gangrene requiring below-the-knee amputation. The patient was successfully decannulated from VA-ECMO on day 20, recovered renal function on day 25, recovered BV function on day 35, and was discharged home on day 48.

Discussion: This case highlights the extreme complications of ACS. Rapid development of cardiogenic shock refractory to transfusions and supportive management (the cornerstone of ACS therapy) calls for more invasive forms of circulatory support. To our knowledge, this is the first case of VA-ECMO use in ACS complicated by refractory BV failure. Early initiation of VA-ECMO in SCD-related RV and BV failure may have a significant role in improving mortality. Currently, this decision is left to physician's discretion. Therefore, guidelines for initiation of VA-ECMO in ACS and BV failure are direly needed.