Case Report
A 53-year-old male with heart failure secondary to ischemic cardiomyopathy and mitral regurgitation underwent CABG and mitral valve repair 3 years prior to presentation with improvement in symptoms. He subsequently developed cardiac arrest requiring dual-chamber ICD placement. He did well for 6 months, until he presented with increased edema and decreased functional capacity. Echocardiography revealed an LV ejection fraction of 15%. Coronary angiography revealed patent bypass grafts without new focal lesions. Right heart catheterization revealed elevated filling pressures and a depressed cardiac index. He was started on intravenous inotropes and an intraaortic balloon pump was placed, however, his hemodynamic status continued to decline. The decision was made to increase level of support to VA ECMO as bridge to transplant (BTT). We decided to use a Bio-medicus NextGen multi-stage cannula for left atrial (LA) VA ECMO in order to obtain left-sided venting and venous drainage simultaneously. Using ultrasound guidance and a micropuncture technique, a right common femoral arterial access was obtained and a 6 French sheath was placed. Right femoral angiography demonstrated a suitable vessel for large-bore access and mapped the superficial femoral artery (SFA) for placement of the antegrade sheath. The access to the SFA was then obtained and a 6 French x 24 cm braided arrow sheath was inserted for antegrade perfusion. The right femoral venous access was obtained using ultrasound guidance and a micropuncture technique and a 7 French sheath was placed. The patient was heparinized to achieve an activated clotting time (ACT) greater than 300 seconds. Next, an SL-1 sheath and BRK needle were used to perform transseptal puncture under real-time transesophageal echocardiographic guidance. The SL-1 sheath was removed and a ProTrackā„¢ wire (Baylis; Mississauga, ON, Canada) was advanced into the LA. Next, the atrial septostomy was performed using a 6 mm x 40 mm peripheral balloon. Then, the venous tract was serially dilated and a 23 French Bio-medicus NextGen cannula multistage was inserted with 4 cm of its tip in the LA, leaving the first set of ports inside of the LA for LV venting, and the second set of ports in the inferior vena cava (IVC) for venous drainage; followed with a 17 French arterial cannula placed in the right common femoral artery and the patient was initiated on LA-VA ECMO. The arterial return cannula was connected to the antegrade perfusion sheath to provide flow to the right lower extremity. The patient remained stable after the procedure, without signs of LV distension and no complications. A suitable donor was available 3 days later, and he underwent a successful heart transplantation.