A Niche Indication for Intra-Aortic Balloon Pump Counterpulsation. Aortic Valve Opening in a Surgically Vented Left Ventricle on Venoarterial ECMO

A50-year-old woman presented with influenza A–associated myocarditis complicated by refractory cardiogenic shock. She was intubated and mechanically ventilated, and received venoarterial extracorporeal membrane oxygenation (ECMO) by femoral cannulation. Vasopressors could then be weaned. ECMO flow was 4 l/min and the aortic valve opened every beat, but there was continuous moderate aortic valve regurgitation and progressive pulmonary edema. Through a lateral thoracotomy, a surgical vent was then advanced in the left ventricular apex via the right upper pulmonary vein and connected to the ECMO drainage tubing, decompressing the left ventricle with 800 ml/min flow through the vent. However, even after lowering total ECMO and vent flow, the aortic valve did not open anymore and there was extensive spontaneous contrast with risk of thrombus formation in the aortic root. Successive implantation of an intra-aortic balloon pump (IABP) and starting 1:1 counterpulsation caused the aortic valve to open with every heartbeat. Aortic valve regurgitation did not increase. Following myocardial recovery, ECMO support was successfully stopped after 10 days and IABP support after 12 days.

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