SPC365

Wake-Up ECMO and PCI in Cardiogenic Shock: A Rescue Strategy for Modified Cabrol Occlusion

Session: MELHORES CASOS CLÍNICOS
Speaker: Andre Lobo

Congress: CPC 2025
Topic: A. Basics
Theme: 02. Clinical Skills
Subtheme: ---
Session Type: Sessão de Casos Clínicos
FP Number: ---
Authors: Andre Lobo; Marta Catarina Almeida; Marta Leite; Inês Neves; António Gonçalves; Inês Rodrigues; Gustavo Pires de Morais; Bruno Melica; Adelaide Dias; Marta Ponte; Daniel Caeiro; Ricardo Fontes-Carvalho

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:&quot;Calibri&quot;,sans-serif">We present the case of a 67-year-old female with a history of rheumatic heart disease and multiple surgeries. She first underwent a mitral valvotomy in 1976 and later a mechanical mitral valve replacement in 2012. In 2024, she required surgical aortic valve replacement, complicated by an aortic root rupture requiring a Bentall procedure with a modified Cabrol technique and VA-ECMO support.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:&quot;Calibri&quot;,sans-serif">She was successfully weaned off ECMO but experienced a 57-day challenging post-operative course, including VATS drainage of a hemothorax and a cardiac arrest.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:&quot;Calibri&quot;,sans-serif">Two months after discharge, the patient was admitted to the emergency department in cardiogenic shock, with profound hypoperfusion and marked hyperlactacidemia (13 mmol/L). TTE revealed new-onset severe biventricular dysfunction without prosthetic valve dysfunction. The ECG showed an LBBB with diffuse ST-segment depression. Vasopressor support with norepinephrine and dobutamine was initiated.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:&quot;Calibri&quot;,sans-serif">Emergent coronary angiography revealed a critical 90% ostial stenosis of the saphenous vein graft used in the proximal anastomosis of the modified Cabrol connection. As the patient experienced worsening hemodynamic status, a decision was made to initiate VA-ECMO support. Due to prohibitive surgical risk, a PCI was also carried out, with a DES deployed in the proximal anastomosis, successfully restoring coronary perfusion. Given the absence of imminent respiratory collapse, invasive mechanical ventilation was avoided. Instead, a &quot;wake-up&quot; ECMO strategy was adopted.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:&quot;Calibri&quot;,sans-serif">The patient was then admitted to the cardiac intensive care unit, where she endured a complicated stay. She experienced continuous blood loss through the arterial cannula, coagulation complications, and an episode of ventricular tachycardia with hemodynamic instability requiring electrical cardioversion. Despite these challenges, there were slow but steady improvements. The patient remained on spontaneous breathing throughout.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:&quot;Calibri&quot;,sans-serif">On the fifth day after VA-ECMO implantation, sustained improvement was observed, with diminishing ECMO support needs. However, she still required high doses of vasopressors and had significant left ventricular dysfunction. Recognizing a small window of opportunity amidst ongoing blood loss and challenging coagulation management, the decision was made to remove VA-ECMO. The decannulation was successfully performed.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:&quot;Calibri&quot;,sans-serif">Following ECMO withdrawal, the patient continued to show gradual improvements. An ICD was placed, and she was eventually discharged with a tailored rehabilitation plan.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Aptos,sans-serif"><span style="font-family:&quot;Calibri&quot;,sans-serif"><strong>Conclusion:</strong> This case underscores the complexity of managing cardiogenic shock in a fragile patient with multiple comorbidities. The decision to pursue early withdrawal of ECMO and avoid invasive ventilation proved essential for favorable outcomes, highlighting the need for a balanced approach to optimize outcomes in critically ill patients</span><span style="font-family:&quot;Calibri&quot;,sans-serif">.</span></span></span></p>

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