Two circulation syndrome following ECMO in patient with

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Two circulation syndrome following ECMO in patient with cardiogenic shock: First experience of VAV

Two circulation syndrome following ECMO in patient with cardiogenic shock: First experience of VAV ECMO Woong-Gil Choi Konkuk University Chungju Hospital

Woong Gil Choi, MD I have no relevant financial relationships

Woong Gil Choi, MD I have no relevant financial relationships

Case Summary • • • Chief complaint: Syncope Age/Sex: 62/M PHx: DM/Hi. BP(+/+) SHx:

Case Summary • • • Chief complaint: Syncope Age/Sex: 62/M PHx: DM/Hi. BP(+/+) SHx: current smoker LAB finding: CK-MB: 13. 9 ng/ml, Troponin-I: 14. 3 ng/ml

ECG

ECG

CXR

CXR

• Cardiac arrest was occurred during transferring to Cath LAB. • Immediate CPR

• Cardiac arrest was occurred during transferring to Cath LAB. • Immediate CPR was initiated prior to arrival at the cath LAB. After successful resuscitation, we started PCI.

Initial CAG

Initial CAG

Thrombus aspiration

Thrombus aspiration

PCI

PCI

Ventricular Fibrillation storm and Patient was collapsed

Ventricular Fibrillation storm and Patient was collapsed

ECMO apply

ECMO apply

Progress • ABGA: p. H: 7. 2 Pa. O 2: 100 mm. Hg PCO

Progress • ABGA: p. H: 7. 2 Pa. O 2: 100 mm. Hg PCO 2: 52 mm. Hg O 2 saturation : 96%. • Although ventilator and ECMO was modified, hypoxemia was not improved. Two circulation syndrome(? ) • ABGA: Pa. O 2: 53 mm. Hg PCO 2: 40 mm. Hg O 2 saturation 86% LPM: 4. 5 L/min, 4, 000 RPM, Fi. O 2 1. 0.

ECMO VA VAV

ECMO VA VAV

Progress_Weaning • ABGA: Pa. O 2 105 mm. Hg PCO 2 29 mm. Hg

Progress_Weaning • ABGA: Pa. O 2 105 mm. Hg PCO 2 29 mm. Hg O 2 saturation 98%

However, the patient was worsened

However, the patient was worsened

• Acute kidney injury was superimposed • Lung compliance was highly stiffened Patient

• Acute kidney injury was superimposed • Lung compliance was highly stiffened Patient was expired after 35 days

Harlequin syndrome or Two circulation syndrome • Bad news is lungs are bad •

Harlequin syndrome or Two circulation syndrome • Bad news is lungs are bad • Good news is heart is ejecting • Rare complication of peripheral VA-ECMO. • As high as 8. 8%

Medical challenges • Optimise mechanical ventilation , add inhaled nitric oxide /prostacyclin • Minimise

Medical challenges • Optimise mechanical ventilation , add inhaled nitric oxide /prostacyclin • Minimise O 2 consumption : sedation, paralysis, hypothermia • Reduce inotrophics if possible • Modulate HR if native CO relatively high • ↑ECMO blood flows transiently

Perfusion challenges • • Change to VV ECMO ± inotropes, IAB/ p. VAD Advance

Perfusion challenges • • Change to VV ECMO ± inotropes, IAB/ p. VAD Advance IVC cannula to RA/SVC VAV : Return oxygenated blood to RA VVA: additional SVC drainage cannula Upper body arterial return: subclavian Central VA ECMO LVAD/Bi. VAD configurations with oxygenator in circuit

Discussion Point • How can we prevent two circulation syndrome? • What were problems

Discussion Point • How can we prevent two circulation syndrome? • What were problems in the late clinical course, especially lung lesion? • Anyway, it is important to manage not only infarcted heart but also overall patient’s condition.

Thank you for your attetion

Thank you for your attetion

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