Scientific Letter
Arrhythmic storm solved with ExtraCorporeal Membrane Oxygenation and consecutive percutaneous coronary intervention and ventricular tachycardia ablation
Tormenta arrítmica resuelta tras angioplastia y ablación bajo soporte con oxigenación de membrana extracorpórea venoarterial
I. Sousa-Casasnovas
, P. Ávila-Alonso, M. Juárez-Fernández, F. Díez-Delhoyo, M. Martínez-Sellés, F. Fernández-Avilés
Corresponding author
Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Sousa-Casasnovas, P. Ávila-Alonso, M. Juárez-Fernández, F. Díez-Delhoyo, M. Martínez-Sellés, F. Fernández-Avilés" "autores" => array:6 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Sousa-Casasnovas" "email" => array:1 [ 0 => "iagosousa@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Ávila-Alonso" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Juárez-Fernández" ] 3 => array:2 [ "nombre" => "F." "apellidos" => "Díez-Delhoyo" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Martínez-Sellés" ] 5 => array:2 [ "nombre" => "F." "apellidos" => "Fernández-Avilés" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tormenta arrítmica resuelta tras angioplastia y ablación bajo soporte con oxigenación de membrana extracorpórea venoarterial" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1442 "Ancho" => 1600 "Tamanyo" => 195839 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pre- (A) and postoperative coronary intervention fluoroscopy (B). Endocardial voltage mapping showing inferior–lateral scar. Electrogram areas with isolated or potentially delayed components (C, blue dots) and ablation sites (D, red dots). c: ECMO venous cannula; p: electrophysiology mapping and imaging catheter.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The arrhythmic storm due to sustained monomorphic ventricular tachycardia (SMVT) is a life-threatening condition in which the catheter ablation procedure is key for management purposes, especially in the presence of a scar.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,2</span></a> Similarly, it is advisable to look for the presence of coronary ischemia and proceed to correct it.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Yet none of these procedures is risk-free, especially in the presence of hemodynamic instability or severe ventricular dysfunction. In this paper we will see an example of the utility of ECMO in this clinical scenario.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A seventy-year-old male was admitted to our center ER after receiving three (3) discharges from his automatic implantable cardiac defibrillator (AICD). He had a prior history of diabetes and arterial hypertension. Also, ten (10) years ago he suffered from an episode of SMVT with a left ventricle ejection fraction (LVEF) of 30%, chronic occlusion of his right and circumflex coronary arteries with lack of viability in such territories based on the single photon emission computed tomography (SPECT) scan, which is why an AICD was implanted followed by amiodarone.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was admitted to the Acute Cardiology Care Unit, his AICD checked, and then it was confirmed that the discharges had been appropriate following an episode of SMVT. While the patient was being monitored, common self-limiting episodes of such arrhythmias were seen, which is why treatment with procainamide in perfusion was prescribed and the AICD therapies disconnected.</p><p id="par0020" class="elsevierStylePara elsevierViewall">This time, the echocardiogram showed a LVEF of 25% and the coronariography showed one severe de novo lesion in the proximal anterior descending artery. After heart-team discussion of the case, it was decided to revascularize the anterior descending artery and perform the ablation of the SMVT. Both were high-risk procedures, which is why hemodynamic support with venoarterial ECMO was taken into consideration.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The intervention was conducted at the electrophysiology lab with intubation, sedation with Propofol, analgesia with remifentanil and cisatracurium for muscle relaxation. In the first place, the left ventricle was accessed using the transseptal puncture technique; then one IV bolus dose of heparin was administered with ECMO support percutaneous implantation through the femoral approach. The Cardiohelp<span class="elsevierStyleSup">®</span> device was used (Maquet, Germany), with a 15<span class="elsevierStyleHsp" style=""></span>F arterial cannula and a 23<span class="elsevierStyleHsp" style=""></span>F venous cannula. The ECMO support was initiated with 1.5<span class="elsevierStyleHsp" style=""></span>bpm and with the possibility of increasing flow if necessary. The next step was to treat the stenosis of the anterior descending artery by implanting one drug-eluting stent (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). During this revascularization, the arterial blood pressure dropped and pulsatility disappeared, which is why the ECMO flow was brought to 3<span class="elsevierStyleHsp" style=""></span>bpm in order to keep the average blood pressure above 60<span class="elsevierStyleHsp" style=""></span>mmHg. This situation was maintained for another 15<span class="elsevierStyleHsp" style=""></span>min due to myocardial stunning, after which pulsatility slowly recovered. And that is when the ablation started. Endocardial voltage mapping during sinus rhythm was created using one multidetector-row catheter with the CARTO<span class="elsevierStyleSup">®</span> 3 system (Biosense Webster Inc., USA); 1.5 and 0.5<span class="elsevierStyleHsp" style=""></span>mV were the voltage limits used to define scar and dense scar. Also, inside the scar, electrogram areas with isolated or potentially delayed components (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) were identified. During the scheduled pacing no SMVTs were induced, but ventricular fibrillation was induced that had to be terminated through defibrillation. Once again, we saw that after the shock a period of several minutes of hypotension and loss of pulsatility followed, during which the ECMO support was increased. Finally, one arrhythmic substrate extensive ablation procedure was conducted (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After finishing the procedure, the patient remained hemodynamically stable and with a good pulse amplitude, which is why it was decided to remove the circulatory support system. The decannulation was conducted in the lab by the vascular surgeon with vein and femoral artery repair. The patient's progression was favorable without SMVT recurrences, and he was discharged from the hospital five (5) days after the procedure.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The case presented here shows the benefits that circulatory support can provide in the management of arrhythmic storms. This support can be necessary in cases of incessant forms of arrhythmia and hemodynamic instability, and also as the back-up of high-risk therapeutic interventions. In particular, the patient described above had a high-risk coronary anatomy with a significant lesion in his only patent blood vessel, which elevated the risk of the revascularization and the ablation procedure.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Today, there are several hemodynamic support devices available to conduct high-risk percutaneous procedures: counter-pulsation balloon, TandemHeart<span class="elsevierStyleSup">®</span>, Impella<span class="elsevierStyleSup">®</span>, venoarterial ECMO.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Of all, the ECMO support guarantees a full circulatory support and a minimum interference when manipulating the catheters. There is prior experience using ECMO support in percutaneous revascularization procedures, in the implantation of percutaneous valves, and in the ablation of arrhythmias,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3–6</span></a> and it has also been used for the hemodynamic rescue of arrhythmic storms.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6,7</span></a> On the other hand, ECMO implantation, initially surgical, has evolved toward percutaneous cannulation, making it a useful tool fully available for all hemodynamic and electrophysiology labs.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Our case illustrates the possibilities of ECMO in the circulatory support of percutaneous devices. Also, it has the peculiarity of being the first case ever reported in medical literature where two (2) consecutive procedures (coronary revascularization and ablation) were conducted with short-term support with the advantage of reducing health care time and avoiding second cannulations.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sousa-Casasnovas I, Ávila-Alonso P, Juárez-Fernández M, Díez-Delhoyo F, Martínez-Sellés M, Fernández-Avilés F. Tormenta arrítmica resuelta tras angioplastia y ablación bajo soporte con oxigenación de membrana extracorpórea venoarterial. Med Intensiva. 2018;42:504–506.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1442 "Ancho" => 1600 "Tamanyo" => 195839 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pre- (A) and postoperative coronary intervention fluoroscopy (B). Endocardial voltage mapping showing inferior–lateral scar. Electrogram areas with isolated or potentially delayed components (C, blue dots) and ablation sites (D, red dots). c: ECMO venous cannula; p: electrophysiology mapping and imaging catheter.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ablation of electrograms with an isolated, delayed component as treatment of unmappable monomorphic ventricular tachycardias in patients with structural heart disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Arenal" 1 => "E. Glez-Torrecilla" 2 => "M. Ortiz" 3 => "J. Villacastín" 4 => "J. Fdez-Portales" 5 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 6 | 9 |
| 2024 October | 54 | 53 | 107 |
| 2024 September | 60 | 30 | 90 |
| 2024 August | 67 | 42 | 109 |
| 2024 July | 52 | 28 | 80 |
| 2024 June | 48 | 37 | 85 |
| 2024 May | 45 | 33 | 78 |
| 2024 April | 55 | 30 | 85 |
| 2024 March | 44 | 27 | 71 |
| 2024 February | 57 | 38 | 95 |
| 2024 January | 48 | 30 | 78 |
| 2023 December | 41 | 34 | 75 |
| 2023 November | 46 | 29 | 75 |
| 2023 October | 56 | 29 | 85 |
| 2023 September | 40 | 38 | 78 |
| 2023 August | 37 | 12 | 49 |
| 2023 July | 51 | 27 | 78 |
| 2023 June | 40 | 16 | 56 |
| 2023 May | 47 | 31 | 78 |
| 2023 April | 67 | 24 | 91 |
| 2023 March | 62 | 31 | 93 |
| 2023 February | 68 | 44 | 112 |
| 2023 January | 33 | 13 | 46 |
| 2022 December | 50 | 27 | 77 |
| 2022 November | 52 | 27 | 79 |
| 2022 October | 56 | 28 | 84 |
| 2022 September | 55 | 41 | 96 |
| 2022 August | 60 | 24 | 84 |
| 2022 July | 41 | 24 | 65 |
| 2022 June | 61 | 28 | 89 |
| 2022 May | 55 | 36 | 91 |
| 2022 April | 72 | 37 | 109 |
| 2022 March | 64 | 59 | 123 |
| 2022 February | 76 | 33 | 109 |
| 2022 January | 69 | 41 | 110 |
| 2021 December | 65 | 43 | 108 |
| 2021 November | 74 | 35 | 109 |
| 2021 October | 141 | 71 | 212 |
| 2021 September | 73 | 41 | 114 |
| 2021 August | 49 | 28 | 77 |
| 2021 July | 42 | 28 | 70 |
| 2021 June | 48 | 30 | 78 |
| 2021 May | 49 | 59 | 108 |
| 2021 April | 106 | 90 | 196 |
| 2021 March | 90 | 30 | 120 |
| 2021 February | 61 | 18 | 79 |
| 2021 January | 86 | 23 | 109 |
| 2020 December | 61 | 19 | 80 |
| 2020 November | 42 | 25 | 67 |
| 2020 October | 50 | 20 | 70 |
| 2020 September | 48 | 18 | 66 |
| 2020 August | 26 | 18 | 44 |
| 2020 July | 44 | 25 | 69 |
| 2020 June | 38 | 16 | 54 |
| 2020 May | 39 | 4 | 43 |
| 2020 April | 53 | 16 | 69 |
| 2020 March | 27 | 10 | 37 |
| 2020 February | 116 | 48 | 164 |
| 2020 January | 46 | 23 | 69 |
| 2019 December | 30 | 16 | 46 |
| 2019 November | 34 | 25 | 59 |
| 2019 October | 21 | 17 | 38 |
| 2019 September | 32 | 15 | 47 |
| 2019 August | 34 | 16 | 50 |
| 2019 July | 34 | 23 | 57 |
| 2019 June | 19 | 10 | 29 |
| 2019 May | 40 | 23 | 63 |
| 2019 April | 16 | 14 | 30 |
| 2019 March | 13 | 12 | 25 |
| 2019 February | 0 | 7 | 7 |
| 2019 January | 0 | 8 | 8 |
| 2018 December | 1 | 2 | 3 |
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