1. Extracorporeal Membrane Oxygenation for Bridge to Decision and to Recovery Shigeki Tabata, Hitoshi Hirose, Nicholas C. Cavarocchi, James T. Diehl, Hiroyuki Abe Thomas Jefferson University, Philadelphia, PA

2. 【 Objective 】 The indications for extracorporeal membrane oxygenation (ECMO) therapy have since grown to encompass both respiratory and cardiac failure and are now being increasingly used in adult patients. We report a patient who traveled from India to the USA and developed acute decompensated biventricular failure and shock requiring ECMO placement as a bridge to decision.

3. 【 Case presentation-1 】 A 66-year-old female who traveled from India to the US presented with severe heart failure and was placed on V-A ECMO for bridge to decision.

4. 【 Chest X-ray before ECMO placement 】 Acute pulmonary edema secondary to severe heart failure

5. 【 Case presentation-2 】 During the first 36 hours the patient lost intrinsic cardiac rhythm while on ECMO. On ECMO day 4, a temporary transvenous endocardial pacing wire was inserted without capture despite optimal placement. Ventricular capture was regained 48 hours later.

6. 【 Chest X-ray after pacing wire insertion 】

7. 【 Case presentation-3 】 Multiple organ dysfunction as well as neurological status improved and were maintained by ECMO support. Further work-up indicated that the patient was not a candidate for heart transplant or permanent ventricular assist device. ECMO support was continued until there was recovery from acute decompensated of chronic heart failure.

8. 【 Case presentation-4 】 ECMO was weaned off with appropriated pharmacological support. The patient was weaned to oral heart failure medications, discharged to a rehabilitation facility and at home in 1 month.

9. 【 Chest X-ray at D/C 】

10. 【 Discussion-1 】 As the technology of the ECMO circuit improved, the patient care during ECMO has focused on the end- organ recovery. During ECMO support, organs such as brain, liver, kidney, lungs, gastrointestinal tract and muscles are well perfused and the temporally malfunctioned organ due to abrupt cardiopulmonary failure will have a chance to recover. In this case, ECMO provided enough flow to vital organs, improving or maintaining end organ functions.

11. 【 Discussion-2 】 ECMO is a temporary device and not designed for long- term use. As the patient was not a candidate for heart transplantation due to several comorbids and the patient body habitus was too small for implantable LVAD, The only option left for this patient was optimal medical treatment. We performed careful bedside ECMO weaning using TEE and successfully decannulated ECMO.

12. 【 Conclusions 】 This is a case of ECMO support for cardiogenic shock complicated with malignant tachyarrhythmia and cardiac arrest. ECMO was able to maintain the organ perfusion without causing any complications. ECMO was removed with pharmacological support without any mechanical cardiac support.