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

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.

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.

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)

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

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

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.

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.

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

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

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