LAVA-ECMO–Supported Dual-Transcatheter Aortic and Mitral Valve-in-Valve Replacement in Cardiogenic Shock

Abstract

Objectives

Mechanical circulatory support is often challenging in patients with cardiogenic shock secondary to valvular heart disease because of challenging device placement, decreased efficacy, the need for a concomitant device for left ventricular unloading, or contraindications. Left atrial venoarterial-extracorporeal membranous oxygenation (LAVA-ECMO) is an emerging technique to achieve simultaneous ventricular unloading and circulatory support unaffected by valvular disease. The use of LAVA-ECMO for high-risk transcatheter valvular replacement has not been described.

Key Steps

We describe the case of a patient with cardiogenic shock resulting from dual aortic and mitral bioprosthetic degeneration who was treated with LAVA-ECMO–supported dual-transcatheter aortic and mitral valve-in-valve replacement.

Potential Pitfalls

Among many precautions worth mentioning, operators should be aware of the care and adjustments of the ECMO circuit required during transcatheter valvular replacement to achieve technical success without complications. The importance of a careful case planning in a multidisciplinary heart team meeting cannot be overemphasized.

Take-Home Message

LAVA ECMO enables high-risk valvular replacement in patients in valvular cardiogenic shock.

Visual Summary

Cardiogenic shock secondary to valvular disease is difficult to manage because of the limited options to provide adequate ventricular mechanical support and ventricular unloading. Venoarterial-extracorporeal membranous oxygenation (VA-ECMO) alone increases afterload and impairs myocardial recovery, and it often requires additional measures for a left ventricular unloading strategy, such as the addition of a microaxial flow pump in the left ventricle.¹ Severe aortic insufficiency impairs the efficacy of the microaxial flow pump and contraindicates the use of an intra-aortic balloon pump. Left atrial venoarterial-extracorporeal membranous oxygenation (LAVA-ECMO)2, 3, 4, 5 involves sending the outflow cannula across a transseptal puncture to draw blood from left and right atria, thereby achieving mechanical support with simultaneous left- and right-sided heart unloading. For our case, we selected upfront LAVA-ECMO instead of conventional VA ECMO with the additional microaxial flow pump because of the patient’s severe aortic insufficiency and stenosis. In addition to the apparent benefit of achieving both ventricular unloading and mechanical circulatory support with a single device, this approach requires only 1 large-bore femoral arterial access instead of 2 large-bore accesses in the case for VA-ECMO and an additional microaxial pump. This approach therefore preserves the other femoral artery for upcoming valvular intervention.

Take-Home Messages

• •LAVA-ECMO enables the performance of high-risk percutaneous valvular procedures that would otherwise not be feasible in patients in cardiogenic shock who have no surgical options.

Case Summary

A 68-year-old woman with degeneration of aortic (23 Magna, Edwards Lifesciences) and mitral (27 Magna, Edwards Lifesciences) bioprostheses, both implanted 10 years earlier, presented in cardiogenic shock with severe aortic insufficiency and stenosis, severe mitral stenosis, a left ventricular ejection fraction of 15%, and cardiorenal syndrome. A transthoracic echocardiogram from an outside institution showed a transaortic mean gradient of 36 mm Hg and a transmitral mean gradient of 14 mm Hg. With progressive cardiogenic shock on increasing doses of multiple inotropes, she was emergently transferred to the cardiac catheterization laboratory of our institution for emergency mechanical circulatory support as a bridge to valvular intervention during the weekend. Cardiac catheterization revealed significantly elevated biventricular filling pressures and confirmed high transvalvular gradients (Figure 1) and a cardiac index of 1.28 L/min/m². Mechanical circulatory support with LAVA-ECMO guided by intracardiac echocardiography (ICE) (Figures 2A to 2F, Video 1) enabled biventricular unloading and recovery of hemodynamics and renal function, followed by planning computed tomography (CT), which showed favorable anatomy—adequate femoral artery diameter for access, adequate aortic bioprosthesis-to–coronary artery distance indicating a low risk of sinus sequestration, and an adequate predicted neo-left ventricular outflow tract (LVOT) area indicating a low risk of LVOT obstruction. The Society of Thoracic Surgeons score predicted mortality rates of 49.5% and 49.8% for isolated surgical aortic and mitral valve replacement, respectively, thus reflecting prohibitive surgical risk. We performed simultaneous percutaneous dual valve-in-valve replacement with prefracture of the aortic bioprosthesis followed by transcatheter aortic valve replacement (TAVR), transcatheter mitral valve replacement (TMVR), and ECMO decannulation (Figures 3A to 3I and 4A to 4F). She was discharged home with outpatient rehabilitation. At 1-month follow-up, she was ambulatory and free of symptoms. Follow-up echocardiography showed recovered ventricular and valvular function (Figures 4C to 4F).

Figure 1.

Overview: Aortic Valve, Mitral Valve, Tricuspid Valve, and Right-Sided Heart Catheterization

LAVA-ECMO = left atrial venoarterial-extracorporeal membrane oxygenation; Max = maximum; PG = pressure gradient; TEE = transesophageal echocardiogram; TMVR = transcatheter mitral valve replacement; V = velocity; VTI = velocity time integral.

Figure 2.

LAVA-ECMO and Work-Up

(A to C) Transseptal puncture, septostomy, and placement of left atrial venoarterial-extracorporeal membrane oxygenation (LAVA-ECMO) cannulas. (D to F) Computed tomography analysis for femoral access, left ventricular outflow tract obstruction risk prediction, and aortic and mitral bioprosthetic dimensions. CAUD = caudal; ICE = intracardiac echocardiogram; LAO = left anterior oblique; LVOT = left ventricular outflow tract; Min = minimum; RAO = right anterior oblique; THV = transcatheter heart valve.

Figure 3.

ViV TAVR and TMVR

(A) Accesses used for concomitant dual valve replacement. (B to D) Valve-in-valve transcatheter aortic valve replacement (TAVR) showing (B) valve crossing, (C) prefracture, and (D) valve deployment. (E to I) Valve-in-valve transcatheter mitral valve replacement (TMVR) with (E) valve crossing, (F) predilation, (G and H) septostomy and valve delivery, and (I) deployment. ECMO = extracorporeal membrane oxygenation; LAVA = left atrial venoarterial; LFA = left femoral artery; LFV = left femoral vein; LV = left ventricle; PA = pulmonary artery; RA = right atrium; RFA = right femoral artery; RFV = right femoral vein; RSFA = right superficial femoral artery; RV = right ventricle; TEE = transesophageal echocardiogram; ViV = valve-in-valve.

Figure 4.

Closure and Follow-Up Transthoracic Echocardiogram

(A) Bidirectional shunt shown through the iatrogenic atrial septal defect (iASD) seen on a transesophageal echocardiogram. The iatrogenic atrial septal defect was closed with an Amplatzer atrial septal defect occluder (B). Extracorporeal membrane oxygenation (ECMO) decannulation and access closure with Manta, Angioseal and Perclose to the right common femoral artery (RCFA), right superficial femoral artery (RSFA), and left common femoral artery (LCFA), respectively, with angiogram taken from the left radial artery. (C) The 1-month follow up echocardiogram showing a good hemodynamic result with no significant aortic or mitral gradient. (E to F) There was persistent pulmonary hypertension. ViV = valve-in-valve.

Procedural Steps

LAVA-ECMO

All accesses were obtained with ultrasound-guided micropunctures. Right internal jugular vein access with a leave-in pulmonary artery catheter was placed. Transseptal puncture was performed through the right femoral vein access with a Brockenbrough needle with a 300-mm Grand slam 0.014-inch coronary wire (Asahi Intecc Medical) inside the Brockenbrough needle guided by ICE from the left femoral vein (Figure 2A). To overcome a stiff septum, septostomy was performed with a 6-mm coronary balloon over the 0.014-inch wire, followed by upsizing to a 0.035-inch Amplatz extrastiff wire with a NaviCross microcatheter (Terumo Interventional Systems), and then septostomy with a 10-mm balloon followed by insertion of a 25-/23-F cannula (LivaNova) through the transseptal puncture with fenestrations of the cannula over both the left and right atria. Right femoral artery access was upsized to an 18-F DrySeal sheath with a hemostatic valve (Gore Medical). Inside the sheath, a 17-F ECMO return cannula was inserted for arterial return at the aortoiliac junction. The return cannula was placed inside the sheath for better hemostasis and easier decannulation (Figure 2C). A 6-F right superficial femoral artery antegrade access was obtained with insertion of a reperfusion sheath with an arrow metal-braided sheath. The ECMO circuit was started. There was significant reduction of mean pulmonary artery pressure and pulmonary capillary wedge pressure, immediately indicating effective unloading of the left and right sides of the heart. The patient’s kidney function recovered over the weekend. CT showed no evidence of LVOT obstruction after TMVR (Figures 2D and 2E) or of coronary obstruction with TAVR.

Dual Valve-in-Valve TAVR With Prefracture and TMVR With Predilation

Valve implantation was performed as an inpatient staged procedure on the next week after a detailed case planning in a multidisciplinary heart team meeting. We deployed a sentinel embolic protection device (Boston Scientific) through a right radial artery access. A left radial artery access was used for the angiographic pigtail. A left femoral artery access was obtained and upsized to 14-F with placement of e-sheaths, preclosed with 2 Percloses (Abbott Cardiovascular). We crossed the aortic valve with a straight-tip glide wire in an AL1 diagnostic catheter while turning down the ECMO flow to 3 L/min (Figure 3B), then switched to a Confida circular-tip wire (Medtronic) in the left ventricle through a pigtail catheter. We fractured the aortic bioprosthesis with a 24-mm True Dilatation balloon (Becton Dickinson) pacing over the Confida wire in the left ventricle at 180 beats/min (Figure 3C), and we then deployed a Sapien 3 23-mm Ultra Resilia valve (Edwards Lifesciences) at nominal pressure pacing over the Confida wire at 180 beats/min and halting the ECMO flow during pacing (Figure 3D). ECMO flows were turned down to 2.5 L, followed by a trial of further reduction in flow, which was unsuccessful. We decided to proceed to TMVR with the accesses as shown (Figure 3A). The patient was intubated, and a transesophageal echocardiogram (TEE) was obtained.

We withdrew the LAVA-ECMO venous cannula from the transseptal position into the inferior vena cava, thus converting LAVA-ECMO to VA-ECMO, and then recrossed the septum with transseptal puncture guided by TEE. The left femoral vein access was upsized to a 16-F e-sheath. We decreased ECMO flow to 1.5 L/min. Conversion to VA-ECMO aided mitral valve opening and crossing while decreasing flow aimed for gradual weaning from ECMO. We crossed the mitral valve with a 0.035-inch glidewire in an Agilis catheter (Abbott Cardiovascular) (Figure 3E) and exchanged it for a J-wire over a NaviCross microcatheter (Terumo Interventional Systems) and then a Confida wire in a multipurpose guide. We predilated with a mitral valvuloplasty with a 28-mm True Dilatation balloon, which did showed a tiny waist (Figure 3F) and agreeing with the plan to use a 26 mm valve.

We then performed septostomy with an 18-mm Atlas balloon (Becton Dickinson) (Figure 3G) to facilitate delivery of a Sapien 3 Ultra Resilia 26 mm valve aided by introduction of of 1 mL of volume into the valve system during delivery of the system across the septum and the mitral valve, which eases delivery by a having a streamline tip (Figure 3H). The valve was deployed balloon at +2 mL under rapid pacing at 180 beats/min and a breath-hold (Figure 3I).

The hemodynamic response to TAVR and TMVR and the setup for each step and key equipment list are shown in the Visual Summary.

Visual Summary. Schematic Diagram of Accesses and Setup for Left Atrial Venoarterial Extracorporeal Membrane Oxygenation, Transcatheter Aortic Valve Replacement, and Transcatheter Mitral Valve Replacement

Baseline hemodynamics and the hemodynamic response to treatment are shown. Key equipment lists for each step of the procedure are as shown. AI/AS = aortic insufficiency/aortic stenosis; ASD = atrial septal defect; ECMO = extracorporeal membranous oxygenation; iASD = iatrogenic atrial septal defect; ICE = intracardiac echocardiogram; IVC = inferior vena cava; LAVA = left atrial venoarterial; LFA = left femoral artery; LFV = left femoral vein; LRA = left radial artery; LV = left ventricle; LVEF = left ventricular ejection fraction; MS = mitral stenosis; PA = pulmonary artery; RFA = right femoral artery; RFV = right femoral vein; RIJV = right internal jugular vein; RRA = right radial artery; RSFA = right superficial femoral artery; TAVR = transcatheter aortic valve replacement; TEE = transesophageal echocardiogram; TMVR = transcatheter mitral valve replacement; TR = transradial; VA = venoarterial.

ECMO Weaning and Closure

In view of impaired right ventricular function with a bidirectional shunt across the iatrogenic atrial septal defect (ASD), we closed the defect with an Amplatzer ASD occluder device (Abbott Cardiovascular) (Figures 4A and 4B). We weaned the patient from ECMO, followed by decannulation. Hemostasis was obtained to the right femoral vein with figure-of-8 sutures, to the left femoral vein with 2 predeployed Percloses, to the right femoral artery with an 18-F Manta (Teleflex) guided by fluoroscopy, to the right superficial femoral artery with a 6-F Angio-Seal (Terumo Interventional Systems), and to the left femoral artery with 2 predeployed Percloses (Abbott Cardiovascular). The left radial artery access was used to park an Armada balloon (Abbott Cardiovascular) in the external iliac artery for provisional balloon assistance during closure and for angiographic confirmation of hemostasis (Figure 4B). Hemostasis to the radial arteries was achieved with transradial bands (TR Bands, Terumo Interventional Systems).

Potential Pitfalls

The LAVA-ECMO outflow cannula position should allow blood to be drawn from the left atrium and the right atrium simultaneously. A cannula with fenestrations spread across a considerable length is required. In this case, we used the LivaNova 2-3/25-F cannula. Septostomy and delivery of the cannula was done over a stiff wire placed in the proximal left upper pulmonary vein. Operators should be aware of the wire position to avoid vascular trauma. A midseptal location for transseptal puncture is preferred. Inadvertent movement of the LAVA cannula should be avoided when securing the cannulas in the groin to avoid the accidental conversion of LAVA-ECMO to VA-ECMO.

When performing percutaneous valvular replacement with LAVA-ECMO running, caution should be taken by interventionists and anesthesiologists when flushing and using any venous accesses because the ECMO circuit could entrain air into the venous system.

Turning down the ECMO flow during and holding respiration on the ventilator can aid stable valve positioning during deployment. Temporarily decreasing the ECMO flow during valve crossing eases the procedure by encouraging valve opening.

TAVR could increase the risk of left ventricular outflow tract (LVOT) obstruction post TMVR by decreasing the neo-LVOT predicted.

This should be considered during case planning.

Conclusions

This case illustrates the treatment of valvular cardiogenic stroke secondary to aortic and mitral bioprosthetic failure with LAVA-ECMO for hemodynamic support and ventricular unloading followed by transcatheter dual valve-in-valve replacement. Awareness of the techniques and potential pitfalls is crucial for performing this high-risk procedure.

Funding Support and Author Disclosures

Dr Lee has served as a consultant for Edwards Lifesciences. Dr Wang has served as a consultant for Edwards Lifesciences, Abbott, and Boston Scientific. Dr B.P. O’Neill has served as a consultant to and has received research support from Edwards Lifesciences. Dr Frisoli has served as a proctor for Edwards Lifesciences, Abbott, Boston Scientific, and Medtronic. Dr W. O’Neill has served as a consultant for Abiomed, Edwards Lifesciences, Medtronic, Boston Scientific, Abbott Vascular, and St Jude Medical; and has served on the Board of Directors of Neovasc. Dr Villablanca has served as a consultant for Edwards Lifesciences and Teleflex. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Annotated Procedural Steps