(1669) Successful Use of Left Atrial VA ECMO in Severe Cardiogenic Shock With LV Thrombus

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is a life-saving intervention for patients with severe cardiogenic shock, serving as an effective bridge strategy for surgical ventricular assist devices, heart transplantation, and myocardial recovery. Left atrial (LA) venting during VA ECMO is crucial to reduce left ventricular (LV) pressure, prevent pulmonary congestion, and facilitate myocardial recovery. The selection of a tailored venting strategy is a key challenge, particularly in patients with LV thrombus.

Description: A 69-year-old female was admitted with parainfluenza pneumonia and myocarditis leading to SCAI class E cardiogenic shock with ejection fraction of 10% and large LV apical thrombus. As she was not optimally supported by medical therapy, and exhibited acute kidney injury (AKI) and liver failure, patient was deemed a candidate for VA ECMO. But presence of LV apical thrombus made options for LV venting difficult. As she was not candidate for impella due to LV thrombus and non-availability of Tandem Heart at our facility; after multidisciplinary discussion, involving cardiology and cardiothoracic surgery teams, the decision was made to proceed with VA ECMO with LA venting through the interatrial septum. The venous cannula was positioned in the mid left atrium across the interatrial septum and the arterial cannula was positioned in the left iliac artery. A 23 French multistage Biomedicus Venous Cannula was used for Left Atrium access across the interatrial septum via the right common femoral vein. Patient was started on ECMO with improvement in lactate. Patient was later transferred to advanced heart failure center for evaluation for heart transplant.

Discussion: The initiation of left atrial VA ECMO involved positioning the venous cannula in the mid-left atrium across the interatrial septum and the arterial cannula in the left iliac artery. This approach provided effective unloading of the left atrium and ventricle, essential in managing the severe LV dysfunction and preventing further complications from the LV thrombus. This case underscores the importance of a tailored approach in managing complex cardiogenic shock with LV thrombus, highlighting the efficacy of LA venting via transseptal cannulation in such high-risk scenarios.