(1638) VA ECMO as a Bridge for Septic Cardiomyopathy in Group A Strep Necrotizing Soft Tissue Infection

Introduction: Necrotizing soft tissue infections (NSTIs), primarily caused by Group A beta-hemolytic Streptococcus (GAS), are characterized by rapid tissue necrosis and severe septic shock. Streptococcal toxic shock syndrome (STSS) occurs in nearly half of NSTI cases involving GAS and carries a mortality rate of up to 40%, necessitating prompt recognition and aggressive surgical intervention. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a potential lifesaving intervention in severe cases of STSS causing cardiogenic collapse.

Description: An adult patient with alcohol use disorder presented with symptoms of NSTI in the right lower extremity. Initially presenting with bruising and bullae after an incident involving a cast iron chair falling on their foot, the patient’s condition rapidly deteriorated. They exhibited extreme tachycardia, tachypnea, tenderness, and leg swelling with bullae formation. Laboratory findings indicated significant hyponatremia, acute kidney injury, and a high LRINEC score, prompting urgent surgical exploration and below-the-knee amputation. Despite surgical intervention and targeted antibiotic therapy, the patient developed severe septic cardiomyopathy with an echocardiogram demonstrating global hypokinesis with an ejection fraction of 11%. VA-ECMO served as a bridge therapy to support cardiac function and stabilize hemodynamics, allowing time to treat systemic STSS, continue to obtain surgical source control and initiate continuous renal replacement therapy for severe electrolyte imbalances due to renal failure.

Discussion: This case underscores the critical role of VA-ECMO in managing severe GAS-induced NSTI complicated by septic cardiomyopathy and systemic complications. VA-ECMO effectively bridged cardiac recovery. The patient was decannulated after source control was achieved. The patient’s family, in this case, decided to proceed with comfort measures despite cardiac recovery, given the patient would require further amputation of their extremities due to complications from disseminated intravascular coagulation. Optimizing VA-ECMO protocols and integrating adjunct therapies like continuous renal replacement therapy is essential to improving outcomes in such complex and severe cases of GAS-associated NSTI causing STSS.