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\begin{document}

\title{Multimodal mechanical circulatory assist for perioperative biventricular
failure}



\author[1]{Yukiharu Sugimura}%
\author[1]{Arash Mehdiani}%
\author[1]{Hug Aubin}%
\author[1]{Philipp Rellecke}%
\author[1]{Udo Boeken}%
\author[2]{Artur Lichtenberg}%
\author[1]{Payam Akhyari}%
\affil[1]{Heinrich-Heine-Universitat Dusseldorf}%
\affil[2]{University Hospital Dusseldorf}%


\vspace{-1em}



  
  \date{June 09, 2024}


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\selectlanguage{english}
\begin{abstract}
A 61-year-old woman with acute myocardial infarction (MI), cardiogenic
shock and Impella CP support underwent emergency coronary artery bypass
grafting. Postoperatively venous-arterial extracorporeal membrane
oxygenation (va-ECMO) became necessary, followed by Impella 5.0
insertion on 7th postoperative day (POD), addition of right ventricular
support by TandemHeart due to inadequate flow of Impella system, which
then allowed for va-ECMO weaning. Impella und TandemHeart were removed
on 14th POD, 31st POD, respectively. Biventricular decompensation
following MI was successfully treated by a sequence of different
mechanical circulatory support systems allowing an adaptive weaning
strategy.%
\end{abstract}%



\sloppy


\textbf{Introduction:}

Cardiogenic shock (CS) after acute myocardial infarction (AMI) or
sustained heart failure after coronary artery bypass grafting (CABG) for
AMI may be refractory to conservative treatment and require mechanical
circulatory support. We report a case of successful sequential recovery
with multimodal mechanical support systems in sustained CS pre and post
CABG.

\textbf{Case Report:}

A 61-year-old woman presenting with dyspnea and acute chest pain on an
emergency base rapidly was diagnosed with anterolateral ST-elevation
myocardial infarction (Creatinin kinase (CK); 2498 U/l, CK-MB; 173U/l,
Troponin T; 5668 ng/l). Coronary angiography revealed long segment
severe stenosis of left anterior descending (LAD), severe stenosis in
the proximal marginal branch of circumflex artery (RM), and segment 2 of
the right coronary artery (Fig 1). Due to CS, Impella CP (by Abiomed)
was implanted in the cath lab through the right femoral artery as
''bridge therapy,'' and the patient was immediately transferred to
undergo CABG. Salvage on-pump CABG was performed with coronary bypasses
to the LAD by the left mammary artery, to RM and posterior descending
artery by a saphenous vein segment. In order to avoid damage to the
Impella during aortic cross clamping and proximal anastomosis of the
bypass grafts Impella CP was removed. Due to severe LV dysfunction
venous-arterial extracorporeal membrane oxygenation (va-ECMO; Centrimag,
by Abbott) via the right femoral vessels was inserted. Myocardial
markers showed a satisfactory course 6 hours after CABG with clear drop
in CK (1504 U/l) and CK-MB (58U/l).

On 7\textsuperscript{th} postoperative day (POD), however, transthoracic
echocardiography (TTE) showed still severely impaired systolic LV
function with global hypokinesia and moderate distention (ejection
fraction; EF 20\%), while respiratory function showed no signs of
impairment. Therefore, it was decided to attempt a switch from va-ECMO
to isolated temporary left ventricular support and unloading by Impella
5.0 in the intention of downgrading the level of support. In the
operation room, a 10mm vascular graft was anastomosed to the right
axillary artery. However, under transesophageal echocardiography (TEE)
as well as fluoroscopic control the Impella 5.0 could not be introduced
beyond the subclavian artery. In this situation, the strategy was
changed, and the arterial line of the va-ECMO was first transferred from
the femoral artery to the axillary artery via already existing
prosthesis. Then a further 10mm silver-coated prostheses was sewn on the
right common femoral artery, and Impella 5.0 was successfully implanted.

Nevertheless, the weaning of va-ECMO was impossible with maximum flow
rates through Impella 5.0 ranging 2.0-2.5 L/min under P3-4 and
additional va-ECMO support of ca. 2.5 L/min \emph{(Fig. 2a)} . The
patient was transferred to the ICU and demonstrated signs of right
ventricle (RV) failure with central venous pressure 23 mmHg when va-ECMO
weaning below 1.5 l/min was attempted. Therefore, a percutaneous RV
assisted device (Tandem-Heart ProtekDuo by LivaNova; run by Centrimag
pump) with integrated oxygenator was implanted via the right internal
jugular vein on 10\textsuperscript{th} POD, allowing termination of
va-ECMO therapy and enabling Impella 5.0 flows reaching a full range of
5.0 L/min for the first time \emph{(Fig. 2b)} .

On 14\textsuperscript{th} POD, TEE demonstrated an external compression
of RA and RV. After hematoma removal via re-sternotomy TEE showed
sufficient recovery of LV and Impella could be removed. The oxygenator
was withdrawn from the RVAD support on 27\textsuperscript{th} POD. TTE
demonstrated LVEF recovered to 50\% with hypokinesis at the septal and
posterior wall, mild mitral regurgitation, mild to moderately depressed
RV function. After pharmacological conditioning with Levosimendan,
Tandem-Heart was successfully removed on 31\textsuperscript{st} POD. Due
to wound healing disorders a further treatment by plastic and
reconstructive surgery became necessary and the patient was finally
discharged for rehabilitation on the
160\textsuperscript{th}postoperative day.

\textbf{Discussion:}

After disappointing results of intra-aortic balloon
pumping\textsuperscript{1-3}, va-ECMO has been the preferred option of
the mechanical circulatory support for sustained CS. However, va-ECMO
does not unload LV, and by increasing the afterload, it may lead to LV
congestion, pulmonary edema, and secondary right heart failure.

Recently, Impella (2.5, CP, and 5.0) has evolved as another valid
catheter-guided mechanical circulatory device for left heart failure.
Impella can produce antegrade flow and additionally unload LV, i.e.,
reduce myocardial oxygen demand and increase the coronary
circulation\textsuperscript{4-7}.

Back to this case, a sequential combination of different systems allowed
for successful step-wise recovery of a patient initially at a very
marginal state with sustained biventricular failure. Impella CP saved
the patient in primary low-output and served as a
bridge-to-revascularization. Termination of the heart-lung machine was
only possible after implantation of va-ECMO. With no sign of relevant LV
recovery on 7\textsuperscript{th} POD, Impella 5.0 was implanted to
terminate va-ECMO, and the Impella was inserted through the femoral
artery as the axillar access was impractical. Retrospectively, we
speculate that 1) either the prosthesis was sewn in a region not
allowing flexible manipulation and introduction of the big caliber of
Impella 5.0 (the pump size is max. 21 Fr; or 2) due to a vertical angle
between the prosthesis and the artery (ideally 45 to 60 degree); or 3)
due to additional borderline diameter of the axillary artery. In a
retrospective view, both the inadequate flow of Impella 5.0 and the
impossibility of va-ECMO weaning were most likely consequences of RV
dysfunction. Actually, Impella 5.0 delivered 5.0 L/min flow after
implantation of TandemHeart ProtekDuo. TandemHeart ProtekDuo is a
percutaneous device for RV support and a valid alternative to surgically
implanted RV assisted device, avoiding additional operative steps. In
our opinion, a stepwise strategy and adaptive weaning pattern with
switch from va-ECMO to Impella 5.0 for the LV support with implantation
of TandemHeart ProtekDuo for the RV support and consecutive weaning of
either univentricular support under differentiated pharmacological
conditioning and close TEE monitoring is a favorable approach for
successful stabilization of critically unstable patients in CS such as
in the present case.

\textbf{Conclusion:}

Biventricular decompensation following MI was successfully treated by a
sequence of different mechanical circulatory support systems allowing an
adaptive weaning strategy.

\textbf{Ethical approval:}

This manuscript followed the principles of the Declaration of Helsinki
and the Declaration of Istanbul. The appropriate informed consent was
obtained for the publication of this manuscript.

\textbf{References:}

1. Thiele H, Zeymer U, Thelemann N, et al. Intraaortic Balloon Pump in
Cardiogenic Shock Complicating Acute Myocardial Infarction: Long-Term
6-Year Outcome of the Randomized IABP-SHOCK II Trial.\emph{Circulation.}
2018.

2. Thiele H, Zeymer U, Neumann FJ, et al. Intra-aortic balloon
counterpulsation in acute myocardial infarction complicated by
cardiogenic shock (IABP-SHOCK II): final 12 month results of a
randomised, open-label trial. \emph{Lancet.} 2013;382(9905):1638-1645.

3. Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support
for myocardial infarction with cardiogenic shock. \emph{N Engl J
Med.}2012;367(14):1287-1296.

4. Griffith BP, Anderson MB, Samuels LE, Pae WE, Jr., Naka Y, Frazier
OH. The RECOVER I: a multicenter prospective study of Impella 5.0/LD for
postcardiotomy circulatory support. \emph{J Thorac Cardiovasc
Surg.}2013;145(2):548-554.

5. Aqel RA, Hage FG, Iskandrian AE. Improvement of myocardial perfusion
with a percutaneously inserted left ventricular assist device. \emph{J
Nucl Cardiol.} 2010;17(1):158-160.

6. Remmelink M, Sjauw KD, Henriques JP, et al. Effects of left
ventricular unloading by Impella recover LP2.5 on coronary
hemodynamics.\emph{Catheter Cardiovasc Interv.} 2007;70(4):532-537.

7. Meyns B, Stolinski J, Leunens V, Verbeken E, Flameng W. Left
ventricular support by catheter-mounted axial flow pump reduces infarct
size. \emph{J Am Coll Cardiol.} 2003;41(7):1087-1095.

\textbf{Figure legends:}

Fig. 1. Preoperative coronary angiography revealed (a) long segment
multiple severe stenoses of left anterior descending, (b) severe
stenosis in the proximal first marginal branch and downstream second
stenosis of circumflex artery, and (c) segment 2 of the right coronary
artery and posterior descending artery. (Black arrows show relevant
stenosis)

Fig. 2. Postoperative chest radiography. (a). Initial support with
venous-arterial extracorporeal membrane oxygenation (black line and
arrows: venous cannula, white line and arrows: Impella; 7th
postoperative day (POD)); (b) later downgrading of support to Impella
(white line and arrows) combined with TandemHeart catheter (black dotted
line and arrows; 11th POD).\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1B/Figure-1B}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-1C/Figure-1C}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-2A/Figure-2A}

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\includegraphics[width=0.70\columnwidth]{figures/Figure-2B/Figure-2B}

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