1. University of Chicago Medicine
Subclavian Intra-Aortic Balloon Pump Followed by Peripheral Veno-Arterial Extra-Corporeal Life Support Prior to Surgical Left Ventricular Assist Device in a Patient with Recent Myocardial Infarction and Progressive Circulatory Collapse: Two Bridges and a Destination
Elizabeth Retzer, MD
Sandeep Nathan, MD, MSc
University of Chicago Medicine
Chicago, IL

2. I/we have no real or apparent conflicts of interest to report.
Elizabeth M. Retzer, MD
I/we have no real or apparent conflicts of interest to report.

3. Clinical presentation
Other co-morbidities
Peripheral Arterial Disease
Chronic Kidney Disease
Multiple prior MIs
Recent DES implants
Paroxysmal AFib
History of prostate CA
Malnutrition
67 year old man with ischemic cardiomyopathy (EF 25%) presents with progressive dyspnea, confusion, acute on chronic renal failure and refractory hypotension.
Recent history of MI/cardiogenic shock requiring inotropic and balloon pump support, complicated by respiratory failure and ischemia/gangrene to right foot.

4. Refractory Cardiogenic Shock
Hospital Course:
Refractory Cardiogenic Shock
Started on Milrinone for inotropic support
Brief initial improvement, followed by progressive decline (increasing lactate, decreased systemic perfusion, shock)
Pressors (dopamine, norephinephrine) initiated
Increasing frequency of tachyarrhythmias (atrial fib, NSVT)
Spiraling hemodynamics / progressive hypoperfusion / multi-organ failure ensued despite extensive support with vasoactive medications
Key clinical considerations:
Progressive shock state
PAD precluding large-bore arterial access with ongoing R foot ischemia following prior arterial cannulation
No residual ischemic/viable myocardium
Not a cardiac transplant candidate (for a variety of reasons)

5. IABP Placement: Subclavian Approach
Given the extensive co-morbidities and clear need for additional hemodynamic support pending a decision on destination-LVAD therapy, the decision was made to proceed with a right subclavian IABP.
This was performed without complications in the OR using a limited cut-down and synthetic graft anastomosed to the RSCA with fashioning of a hemostatic valve through which a Maquet 7.5 Fr. IABP was placed into the descending aorta
Raman et al. Ann Thorac Surg 2010;90:1032-4

6. Hospital Course Continued: Following IABP Placement
Continued patient decompensation:
Increasing pressor requirement despite IABP
Worsening tachyarrythmias during which there was no IABP augmentation
Worsening perfusion (increasing lactate, decreasing SVO2)
Decision made to initiate percutaneous extracorporeal life support [V-A ECLS (ECMO)] after extensive discussion between Interventional Cardiology, Cardiothoracic Surgery and Heart Failure / Transplant

7. ECMO Cannula Placement:
Femoral Approach with Antegrade Sheath
Antegrade 6 Fr Arrow sheath in SFA for limb perfusion
15 Fr arterial cannula (Medtronic BioMedicus)
21 Fr venous cannula (Medtronic BioMedicus)
Extracorporeal life support (ECLS) was initiated in the cardiac cath lab using the Maquet CardioHelp system and peripherally placed cannulae.

8. Maquet Cardiohelp ECLS Console
Counterpulsation with ECMO & IABP
IABP Console
Maquet Cardiohelp ECLS Console
Decision was made to leave subclavian IABP in place for coronary perfusion while circulatory / oxygenation support was provided by ECLS circuit.

9. IABP on Hold: Complete Loss of Intrinsic Cardiac Pulsatility
IABP Console
ICU Monitoring Screen

10. Hospital Course Continued: Improvement on Combined Therapy
Perfusion parameters begin improving with combination IABP and ECLS
Decreasing lactate
Improving renal function, urine output without diuretic support
Vasoactive medications slowly able to be weaned off
With increasing stability, patient able to receive permanent LVAD (Thoratec HeartMate II) on post-ECLS day 3

11. Summary
Multiple medical / surgical considerations in the management of refractory cardiogenic shock
Graded medical / mechanical support as a bridge to destination therapy
Successful combined use of subclavian IABP and peripheral ECLS with prophylactic antegrade limb perfusion.
Collaboration between Interventional Cardiology, Cardiothoracic Surgery and Heart Failure/ Transplantation Services
Successful bridge to destination LVAD