++
Case Presentation
A 62-year-old man came into the emergency department for sudden onset of angina that started 2 hours before the presentation and woke him up from sleep. He was known to have diabetes mellitus, hypertension, and hyperlipidemia. When the emergency medical service arrived, the electrocardiogram showed inferior wall ST-segment elevation myocardial infarction, and he was rushed to the hospital. En route, he continued to have chest pain that was not relieved by nitroglycerine; he was loaded with aspirin. His vital signs showed a blood pressure of 110/75 mmHg, a pulse of 75 bpm, and oxygen saturation of 98% on a 2-L nasal cannula, and the patient was afebrile. He was taken to the cardiac catheterization lab on hospital arrival for emergent revascularization. In the catheterization lab, he had a cardiac arrest with ventricular fibrillation. He was shocked and cardiopulmonary resuscitation (CPR) was initiated with no return of spontaneous circulation (ROSC). He was intubated and placed on mechanical ventilation. His initial blood gas showed pH of 7.01, PCO2 of 65 mmHg, PaO2 of 40% on fraction of inspired oxygen (FiO2) 100%, and HCO3 of 8. CPR was continued, and ROSC was achieved in 15 minutes with mean arterial pressure (MAP) around 55 mmHg and lactic acid of 12 mmole/liter with multiple pressers. A diagnostic coronary angiogram showed thrombotic occlusion of the right coronary artery (RCA). The decision was made to initiate venoarterial extracorporeal membrane oxygenation (VA-ECMO) given cardiogenic shock requiring percutaneous coronary intervention (PCI).
The patient was started on VA-ECMO via femoral cannulation with a flow rate of 3.5 to 4 L/min with intra-aortic balloon pump (IABP) insertion with 1:1 augmentation. He underwent PCI of the RCA with a drug-eluting stent placed and Thrombolysis in Myocardial Infarction (TIMI) III flow. His mixed venous oxygen saturation was maintained at 60% to 80%. The dobutamine and epinephrine drips were titrated to maintain a goal cardiac index greater than 2.2 L/min/m2. Day 1 echocardiogram showed an ejection fraction of 20%, but patient hemodynamics continued to improve. Subsequently, he was able to be weaned off dobutamine and pressor. The repeat echocardiogram on day 6 showed an ejection fraction of 55% with central venous pressure (CVP) of 5 mmH2O and pulmonary capillary wedge pressure (PCWP) of 12 mmH2O. The patient was gradually weaned off extracorporeal membrane oxygenation (ECMO), and the patient was successfully extubated on the following day. He continued to feel better and was eventually discharged home.
++
KEY POINTS
ECMO is a heart-lung machine that is used in patients who require temporary cardiac or pulmonary support while they are recovering from injury.
ECMO’s primary role is pumping of the blood and oxygenation of the blood.
Monitoring of the ECMO circuit is essential to avoid complications.
A trained staff is vital for the success of ECMO use.
+++
HISTORICAL PERSPECTIVE
++