Unfortunately, VA ECMO has very little to offer Kenneth. While it provides excellent support for acute heart failure and hemodynamic decompensation from ischemic disease, myocarditis, cardiomyopathy, mitral stenosis, mitral regurgitation, and aortic stenosis by providing a safe environment for rest, intervention or medical treatment, it cannot support a patient with an incompetent aortic valve. The continuous flow from the circuit into the arterial circulation floods and distends the LV causing ischemia and myocardial cell death. Venting the LV is not an option since that just returns the flow from the LV to the circuit like a shunt, without improving perfusion to the body and other organs. Kenneth’s only option is urgent surgery, which is what was recommended.

While this was being set up, he had a period of hypotension and suffered a PEA arrest. He was placed on ECMO as ECPR, understanding that the LV would be distended and potentially damaged, and then directly to the OR where he underwent an emergency redo aortic valve replacement, annular reconstruction and ascending aorta replacement. He failed to wean from CPB with poor LV function and was pacer dependent with complete heart block, so was stabilized on VA ECMO. Despite adequate flows, he unfortunately appeared to have severe autonomic dysfunction with severe vasodilation unresponsive to drugs and expired from multisystem organ failure.

As a side note, this was a very high-risk endeavor to attempt to rescue a relatively young patient. In a similar circumstance when the patient with severe AI is placed on VA ECMO as a rescue to get to the OR, the LV is almost certainly going to be very sick after the procedure, and it is probably advisable to just plan on transitioning from CPB to VA ECMO, including an LV vent, to rest the LV as much as possible and give it every chance possible to recover, or to keep open any option for bridging to VAD and/or transplant.