Successful Re-Transplantation With ECMO/IABP And Inter-Atrial Septostomy As A MCS Bridge For Cardiogenic Shock Due To Cardiac Allograft Vasculopathy

R. Anantharaman1, N Madhusankar2, S. Cherian2, KM. Cherian2

1Senior Consultant Interventional Cardiologist, Kauvery Hospital, Chennai, India

2Frontier Lifeline Hospital, Dr K M Cherian Heart Foundation, Chennai, India

Abstract

Cardiac Allograft Vasculopathy is the Achilles heel of survival following heart transplantation. We discuss a case of cardiogenic shock due to severe cardiac allograft vasculopathy eight years post-transplant, which was successfully bridged to re-transplantation with ECMO/IABP as mechanical circulatory support (MCS) and Inter-atrial septostomy for left heart decompression. At 4 years follow up patient is asymptomatic with good graft function.

Case Presentation

A 36-years-aged female athlete was diagnosed with post viral myocarditis and dilated Cardiomyopathy with stage IV heart failure, for which she underwent a successful orthotopic heart transplant in 2009. Following this, she has been under regular follow up leading a near-normal life, and has represented India in Transplant Olympics in 2017 in 100 m. In May 2017, her echo showed mild RV dysfunction with good LV systolic function, and coronary angiography confirmed Cardiac Allograft Vasculopathy (CAV) affecting all 3 coronaries (Figs. 1 and 2), her RV endomyocardial biopsy (EMB) showed no evidence of rejection. Her medical treatment was optimized and was advised for the close follow-up to decide on a re-do heart transplantation.

ECMO-IABP-1Fig 1. CAV of RCA.

ECMO-IABP-2Fig. 2. CAV of LCA.

She presented to the hospital in September 2017, in cardiogenic shock in peri-arrest state with a high level of lactate (> 19) with severe acidosis. She was successfully resuscitated and initial circulatory support was provided by IABP and inotropes. A few hours later percutaneous Femora-Femoral VA-ECMO was done, following this her hemodynamics was stabilised and acidosis corrected with normal lactate levels. The next day she underwent percutaneous balloon atrial septostomy (BAS) for left heart decompression (Fig. 3). Re-do heart transplant was done on the third day successfully, and she was discharged on the twelveth day following an EMB showing no acute rejection. On follow up she is stable and asymptomatic at 4 years.

ECMO-IABP-3Fig 3. Balloon atrial septostomy (BAS) with 24 mm Inoue Balloon.

Conclusion

CAV is a leading cause of late death after heart transplantation. Early rapid intimal thickening predicts adverse cardiac outcomes, including reduced survival, hence IVUS to identify early CAV is essential.

Current management is focused on prevention strategies directed at modifiable immune and nonimmune targets. The mTORi have been a significant advance in slowing progression of CAV. In severe form of CAV (CAV3) with significantly reduced left ventricular function re-transplantation is the only viable option. This case highlights the importance of early mechanical circulatory support (MCS) with ECMO is crucial in stabilizing the hemodynamics and prevent hepato-renal dysfunction before re-transplantation.

Dr-R-Anantharaman

Dr. R. Anantharaman

Senior Consultant Interventional Cardiologist

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