A 32-year-old female with no prior medical history presents with several days of fevers, chills, myalgias, and progressive shortness of breath. She is found to have a blood pressure of 84/70, heart rate of 123, and oxygen saturation of 84% on room air. She is admitted to the ICU and an urgent echocardiogram shows a left ventricular ejection fraction of 15%, normal left ventricular end diastolic diameter, and severe right ventricular systolic dysfunction. She is started on intravenous norepinephrine and dobutamine, given intravenous furosemide and is intubated for progressive hypoxia; however, she remains persistently hypotensive with poor urine output despite escalating doses of intravenous therapy and diuretics.
Which of the following would be the most appropriate choice for mechanical circulatory support in this patient?
A. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO)Correct Answer: A
VA-ECMO is the best choice for mechanical circulatory support for this patient given the need for both cardiac and respiratory support. Indications for VA-ECMO include refractory cardiogenic shock, cardiac arrest, massive pulmonary embolism, and failure to wean from cardiopulmonary bypass after cardiac surgery. In the setting of biventricular failure with both severe right and left ventricular dysfunction, a LVAD (either percutaneous or surgical) alone is insufficient and can often worsen right ventricular function when placed for isolated left ventricular failure. Although there are no contraindications to IABP placement in this setting, it would be unlikely to provide sufficient hemodynamic support given her refractory cardiogenic shock, and would not directly support oxygenation. VV ECMO would only provide oxygenation, but no hemodynamic support, and thus not useful in this patient.
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