Abstract
Background
Left ventricular thrombus complicating advanced cardiomyopathy poses challenges for mechanical circulatory support, especially when venting is required.
Case Summary
The patient presented with anterolateral ST-segment elevation myocardial infarction from left ventricular thrombus embolization and underwent revascularization. He experienced arrest and was placed on venoarterial extracorporeal membrane oxygenation (ECMO). Extensive intracardiac thrombus contraindicated venting with a microaxial temporary left ventricular assist device (LVAD). Venoarterial ECMO was reconfigured to left atrial venoarterial ECMO (LAVA-ECMO), providing effective venting and hemodynamic support. Heart transplantation was deferred because of comorbidities. He was successfully bridged to high-risk durable LVAD implantation using meticulous surgical techniques.
Discussion
LAVA-ECMO enabled safe and effective venting when other typical strategies were contraindicated. This facilitated hemodynamic stabilization and successful bridging to definitive therapy.
Take-Home Messages
LAVA-ECMO offers an alternative for left atrial venting when other methods are contraindicated. Durable LVADs can be safe in patients with extensive intracardiac thrombus using careful surgical techniques.
Key words: acute myocardial infarction, cardiogenic shock, durable left ventricular assist device, left atrial venting, left ventricular thrombus
Graphical Abstract
History of Presentation
A 31-year-old man presented to our emergency department after 1 week of worsening dyspnea, chills, and chest tightness. Blood pressure was 108/67 mm Hg, heart rate was 131 beats/min, and oxygen saturation was 97%. His physical examination revealed rales.
Past Medical History
The patient’s medical history included asthma, hypertension, and repaired scoliosis.
Differential Diagnosis
His differential diagnosis included acute coronary syndrome, myocarditis, pneumonia, and pleural process.
Investigations
An electrocardiogram showed ST-segment elevations in leads V2 and V4 to V6 consistent with anterolateral ST-segment elevation myocardial infarction (STEMI) (Figure 1). Chest x-ray demonstrated pulmonary edema (Figure 2). The initial high-sensitivity troponin T level was 574 ng/L (normal <12 ng/L), and the B-type natriuretic peptide level was 23,803 pg/mL.
Figure 1.
Initial Electrocardiogram
This figure demonstrates anterolateral ST-segment elevation myocardial infarction.
Figure 2.
Initial Chest X-Ray
This figure demonstrates pulmonary edema.
Management
He was immediately taken to the catheterization laboratory and found to have 100% proximal left anterior descending artery occlusion (Figure 3). He underwent percutaneous transluminal coronary angioplasty of the proximal left anterior descending artery. During the procedure, he had worsening ST-segment elevations and was found to have acute thrombus in the left circumflex system, requiring aspiration thrombectomy and percutaneous transluminal coronary angioplasty of the obtuse marginal branches. Tirofiban, aspirin, and heparin were initiated. A femoral intra-aortic balloon pump (IABP) was inserted.
Figure 3.
Coronary Angiography Before Revascularization
Complete occlusion of the proximal left anterior descending artery. Further investigation revealed embolization of left ventricular thrombus to be the cause.
In the coronary intensive care unit, transthoracic echocardiography showed a severely dilated left ventricle (LV) with global hypokinesis and aneurysmal apex, as well as an ejection fraction of 15%. Apical LV thrombus was identified, with embolization suspected as the cause of his STEMI (Video 1, Video 2, Video 3). The right ventricle was dilated with moderately decreased function.
Two hours later, he experienced ventricular fibrillation arrest with return of spontaneous circulation after 1 minute of resuscitation. He was intubated, and a pulmonary artery catheter was placed, showing a Fick cardiac index of 1.15 L/min/m2, pulmonary artery (PA) pressures of 53/42 mm Hg, and a pulmonary capillary wedge pressure (PCWP) of 42 mm Hg (Table 1). Given his ongoing hemodynamic insufficiency, venoarterial extracorporeal membrane oxygenation (ECMO) was initiated with left common femoral vein (CFV) drainage and left common femoral artery reinfusion.
Table 1.
Hemodynamics Before and During Extracorporeal Membrane Oxygenation
| Timepoint |
|||||
|---|---|---|---|---|---|
| Before VA-ECMO, After ROSC From Cardiac Arrest | On VA-ECMO Before LA Cannula Placement | Initially on LAVA-ECMO | 24 h on LAVA-ECMO | Day 4 on LAVA-ECMO, Just Before LVAD | |
| PA pressures (mm Hg) | 53/42 | 34/28 | 26/17 | 21/15 | 23/12 |
| RA pressure (mm Hg) | 23 | 19 | 14 | 18 | 17 |
| ECMO flow (L/min) | — | 3.7 | 4 | 5 | 6 |
| Vasoactive medications | None | None | Vasopressin 0.06 U/min | Vasopressin 0.06 U/min, phenylephrine 25 μg/min | None |
| Other support | IABP | IABP | IABP | IABP | None |
Pulmonary capillary wedge pressures are not presented in this table as they were not captured at multiple timepoints to demonstrate the trend throughout the patient's course.
A patient with complete left ventricular thrombosis in cardiogenic shock who required temporary mechanical circulatory support was successfully bridged to a high-risk durable left ventricular assist device using left atrial venoarterial extracorporeal membrane oxygenation for hemodynamic support and left atrial venting and careful intraoperative techniques to prevent embolism.
ECMO = extracorporeal membrane oxygenation; IABP = intra-aortic balloon pump; LA = left atrial; LAVA = left atrial venoarterial; LVAD = left ventricular assist device; PA = pulmonary artery; PCWP = pulmonary capillary wedge pressure; RA = right atrial; ROSC = return of spontaneous circulation; VA = venoarterial; “—" = not measured/not recorded.
A repeat echocardiogram demonstrated a closed aortic valve with diffuse acute-on-chronic LV thrombus obliterating the cavity (Video 4, Video 5). Because of ongoing pulmonary edema and elevated PCWP and PA pressures, a multidisciplinary shock team meeting was held regarding venting strategies. A microaxial temporary left ventricular assist device (LVAD) was contraindicated because of extensive LV thrombus and risk for repeat embolization. Thus, we decided to reconfigure mechanical circulatory support to left atrial venoarterial (LAVA) ECMO, aiming to reduce PCWP and improve pulmonary edema (Figure 4). The patient went to the catheterization laboratory for the placement of a ProtekSolo (LivaNova) transseptal left atrial (LA) cannula via the right CFV, which was Y-connected to the left CFV cannula. He was initiated on LAVA-ECMO with consistent flows of 4.0 L/min, alongside continued IABP support and no inotropes. Flows were adjusted to maintain aortic valve closure to prevent embolization and catastrophic neurologic injury. Heparin was continued throughout LAVA-ECMO support. The IABP was removed the next day.
Figure 4.
Chest X-Ray Before Surgery
(A) At the time of venoarterial extracorporeal membrane oxygenation (ECMO) initiation, before venting. (B) After 4 days of left atrial venoarterial (LAVA)-ECMO, just before durable left ventricular assist device implantation. This figure demonstrates significant improvement in pulmonary edema with left atrial venting on LAVA-ECMO.
Given his advanced cardiomyopathy and persistent cardiogenic shock, he was urgently evaluated for advanced heart failure therapies and listed as status 1 for heart transplantation on day 1. He was then found to have untreated human immunodeficiency virus (HIV) with a viral load of 10,800 copies/mL and a CD4+ count of 415 cells/μL and transitioned to inactive status 7. Given his continued need for definitive therapy, he was approved for high-risk durable LVAD implantation with a HeartMate 3 system (Abbott) as a bridge to transplantation.
He went to the operating room on day 4. Standard median sternotomy was performed. After systemic heparinization, cardiopulmonary bypass (CPB) was initiated using the left common femoral artery cannula, bilateral Y-connected CFV cannulas, and an additional superior vena cava cannula. During transition from ECMO to CPB, temporary pacing at 180 beats/min was initiated to prevent LV ejection and embolization. Heart manipulation before aortic cross-clamping was minimized. Although we routinely perform beating-heart LVAD implantation, we decided to cross-clamp the aorta to prevent ejection and embolization during manipulation and CPB adjustments. The cross-clamp was applied, and antegrade cardioplegia was administered. The right atrium was opened, the LA cannula was withdrawn, and the LA was irrigated. The atrial septal defect was closed primarily. An aortotomy revealed no aortic root or LV outflow tract thrombus. The LV apex was exposed and cored, revealing extensive thrombus—both fresh and mature laminated—with diffuse involvement of the trabecula and septum (Figure 5). The entire thrombus was meticulously removed through the apex, followed by thorough irrigation and inspection of the LV. The HeartMate 3 system was inserted into the apex with the outflow graft anastomosed to the ascending aorta. Because of right ventricular failure upon weaning from CPB, a central right ventricular assist device (RVAD) was placed using an 8-mm graft anastomosed to the PA and the existing left CFV cannula, and an oxygenator was spliced into the circuit. All other cannulas were removed. Because of profound coagulopathy and ongoing bleeding, the chest was left open with temporary closure. Initial LVAD flows were 3.1 L/min at 4,900 RPM, and RVAD flows were 2.5 L/min at 1,900 RPM. On postoperative day (POD) 1, he underwent washout and chest closure, and on POD 5, he underwent uneventful RVAD decannulation and extubation. Therapeutic heparin and aspirin 81 mg were started POD 1 after chest closure, and warfarin with a target international normalized ratio of 2-3 was started POD 5 after RVAD decannulation.
Figure 5.
Intraoperative Findings
Extensive left ventricular thrombus with acute and mature laminated components. Meticulous thrombus removal through the apex, followed by thorough irrigation and inspection of the cavity, before left ventricular assist device insertion was critical.
Discussion
We describe a patient with undiagnosed nonischemic cardiomyopathy and LV thrombus, who presented with acute STEMI from embolization. After attempted revascularization, he experienced arrest requiring emergent venoarterial ECMO. Because of high afterload from ECMO and intrinsic LV failure, he developed profound thrombus obliterating the entire LV. Given the thrombus burden, our preferred venting strategy of a microaxial temporary LVAD was contraindicated. Thus, LAVA-ECMO was used via transseptal puncture with improvement in pulmonary pressures and edema. Strategies to prevent catastrophic embolization included high ECMO flows to ensure aortic valve closure, avoidance of inotropes, and uninterrupted anticoagulation. He remained stable on LAVA-ECMO as a bridge to urgent advance therapy.
On isolated venoarterial ECMO, increased afterload can raise LV end-diastolic pressure, with the backup of pressure leading to elevated PCWP and pulmonary edema.1,2 In this case, the LV was completely thrombosed, further raising PCWP and worsening pulmonary congestion. Given the patient's unsalvageable heart, advanced therapies were necessary. Thus, venting on venoarterial ECMO before definitive surgery was essential to success by preventing continued PCWP escalation and pulmonary congestion, which could have significantly increased the risk of fulminant pulmonary edema and acute respiratory distress syndrome upon transition to heart transplantation or durable LVAD implantation.3
Although our preferred venting strategy for venoarterial ECMO is a microaxial temporary LVAD, typically an axillary Impella 5.5 (Abiomed), this was contraindicated because of the high thromboembolic risk of placing the device in a thrombosed LV.4 Thus, we reconfigured venoarterial ECMO to LAVA-ECMO using a transseptal LA cannula for venting. This configuration can rapidly reduce left-heart and pulmonary pressures in cardiogenic shock and is associated with successful bridging outcomes comparable to those achieved with Impella.5,6 In our patient, LAVA-ECMO provided effective hemodynamic support with resolution of pulmonary edema and enabled successful transition to durable LVAD implantation. We decided to use an LA cannula rather than atrial septostomy to avoid direct atrial communication in the setting of thrombus. We also kept the original CFV cannula rather than switching to a multistage drainage cannula to maintain uninterrupted ECMO flow, continuously preventing the heart from ejecting and risking thromboembolism. Although LAVA-ECMO has shown efficacy in cardiogenic shock with significant LV thrombus and as a bridge to advanced therapies, we present a successful case involving both.7,8
Although heart transplantation was initially our preferred exit strategy given the extensive thrombus burden, the patient's untreated HIV was a contraindication, prompting consideration for durable LVAD implantation despite diffuse LV thrombus. Evidence surrounding the safety of durable LVADs in patients with LV thrombus remains mixed. A series of 525 patients with HeartMate 2 and 3 found that the presence of thrombus independently predicted stroke and death at 6 months, yet another series of 563 patients reported that survival free from stroke and pump thrombosis at 30 days was similar among patients with and without thrombus.9,10 In our case, the patient needed expedient definitive therapy, and a durable LVAD was the only option. We were able to mitigate the risk through careful intraoperative techniques, with no major thromboembolic or pump thrombosis events. Rapid pacing to minimize thrombus transit during transition from ECMO to CPB, minimal heart manipulation, early cross-clamping, meticulous thrombus removal, and copious irrigation before LVAD implantation were critical.
Outcome and Follow-Up
The postoperative course included multiple ventricular tachycardia episodes requiring cardioversion and pleural effusion requiring drainage. He was weaned off vasopressors on POD 7, transferred to the stepdown unit on POD 19, and discharged to an acute rehabilitation facility on POD 53. At discharge, his LVAD was functioning properly, flowing 4.4 L/min at 5,100 RPM.
Conclusions
This case demonstrates the utility of LAVA-ECMO as a bridge to definitive therapy in a patient with cardiogenic shock and complete LV thrombosis. This configuration allowed for hemodynamic stabilization and effective LA venting. When Impella insertion for venting is contraindicated, LAVA-ECMO is an alternative strategy. In addition, durable LVAD implantation can be safe despite extensive intracardiac thrombus when careful intraoperative techniques and perioperative management are used.
Funding Support and Author Disclosures
Dr Soltesz is the Donna and Ken Lewis Endowed Chair in Cardiothoracic Surgery. Dr Tong has received honoraria from Abbott and Abiomed. Dr Soltesz has received honoraria from Abbott, Abiomed, AtriCure, and Dilon. Dr Zaki has received honoraria from Abiomed. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Take-Home Messages
-
•
In this patient with cardiogenic shock and LV who required temporary mechanical circulatory support, left atrial venoarterial extracorporeal membrane oxygenation reduced pulmonary pressures and relieved pulmonary edema while also mitigating the risk of thromboembolism inherent to other venting strategies.
-
•
In this patient with complete LV thrombosis who required advanced heart failure therapy, although heart transplantation was initially preferred, durable left ventricular assist device implantation was a safe and effective alternative when comorbidities contraindicated transplantation.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
Equipment List.
| Imaging guidance |
|
| Access and ECMO circuit |
|
Visual Summary.
| Timeline | Events |
|---|---|
| Day 1—initial presentation and management | A 31-year-old man presented with STEMI. Angiography showed a 100% occluded LAD → PTCA of the LAD. Worsening ST-segment elevations during the procedure → acute thrombus found in the left circumflex system → aspiration thrombectomy and PTCA of obtuse marginal branches. |
| Day 1—in the CICU | Echocardiography showed apical thrombus and severe LV dysfunction. Cardiac arrest → emergent VA-ECMO initiated. Continued to have pulmonary edema with high pulmonary pressures on VA-ECMO. Repeat echocardiography showed acute LV thrombus with complete obliteration of the cavity → Venting with a microaxial temporary LVAD contraindicated. |
| Day 1—return to the catheterization laboratory | Multidisciplinary shock team discussion → returned to the catheterization laboratory for the placement of a percutaneous transseptal LA venting cannula. VA-ECMO reconfigured to LAVA-ECMO → reduction in pulmonary pressures and pulmonary edema. |
| Day 1—return to the CICU | Multidisciplinary discussion → listed for heart transplantation as status 1. |
| Day 2 | During further evaluation, found to have undiagnosed HIV→ transitioned to inactive status 7. Approved for high-risk durable LVAD implantation. Continued to remain stable on LAVA-ECMO support with resolution of pulmonary edema. |
| Day 4 | Underwent successful durable LVAD implantation using careful surgical techniques. RV dysfunction when weaning from bypass → a temporary RVAD placed, chest left open. |
| Day 5 (postoperative day 1) | A temporary RVAD decannulated, chest closed, extubated. |
| Day 58 (postoperative day 54) | Discharged to an acute rehabilitation facility after resolution of postoperative complications. |
Appendix
Transthoracic Echocardiogram
After return of spontaneous circulation after cardiac arrest, before initiation of extracorporeal membrane oxygenation. Evidence of severe left ventricular dysfunction with chronic apical thrombus.
Transthoracic Echocardiogram
After return of spontaneous circulation after cardiac arrest, before initiation of extracorporeal membrane oxygenation. Evidence of severe left ventricular dysfunction with chronic apical thrombus.
Transthoracic Echocardiogram
After return of spontaneous circulation after cardiac arrest, before initiation of extracorporeal membrane oxygenation. Evidence of severe left ventricular dysfunction with chronic apical thrombus.
Transthoracic Echocardiography
On venoarterial extracorporeal membrane oxygenation support before insertion of a transseptal left atrial cannula for venting. This video demonstrates extensive acute-on-chronic left ventricular thrombus with complete obliteration of the cavity.
Transthoracic Echocardiography
On venoarterial extracorporeal membrane oxygenation support before insertion of a transseptal left atrial cannula for venting. This video demonstrates extensive acute-on-chronic left ventricular thrombus with complete obliteration of the cavity.
References
- 1.Jain P., Salama M., Everett K., Reyelt L., Kapur N.K. To vent or not to vent: a loaded question during venoarterial extracorporeal membrane oxygenation support for cardiogenic shock. Circ Cardiovasc Interv. 2021;14(5) doi: 10.1161/CIRCINTERVENTIONS.121.010537. [DOI] [PubMed] [Google Scholar]
- 2.Ezad S.M., Ryan M., Donker D.W., et al. Unloading the left ventricle in venoarterial ECMO: in whom, when, and how? Circulation. 2023;147(16):1237–1250. doi: 10.1161/CIRCULATIONAHA.122.062371. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Park H., Yang J.H., Ahn J.-M., et al. Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: the EVOLVE-ECMO randomized clinical trial. Eur J Heart Fail. 2023;25(11):2037–2046. doi: 10.1002/ejhf.3014. [DOI] [PubMed] [Google Scholar]
- 4.Hess N.R., Ziegler L.A., Kaczorowski D.J. The 10 commandments of microaxial temporary left ventricular assist devices. Innovations. 2022;17(5):368–376. doi: 10.1177/15569845221134514. [DOI] [PubMed] [Google Scholar]
- 5.Inglis S.S., Rosenbaum A.N., Rizzo S.A., et al. Novel left ventricular unloading strategies in patients on peripheral venoarterial extracorporeal membrane oxygenation support. ASAIO J. 2024;70(5):396–403. doi: 10.1097/MAT.0000000000002136. [DOI] [PubMed] [Google Scholar]
- 6.Villablanca P.A., Fadel R.A., Giustino G., et al. Hemodynamic effects and clinical outcomes of left atrial veno-arterial extracorporeal membrane oxygenation (LAVA-ECMO) in cardiogenic shock. Am J Cardiol. 2025;236:79–85. doi: 10.1016/j.amjcard.2024.11.005. [DOI] [PubMed] [Google Scholar]
- 7.Phillip R., Howard J., Hawamdeh H., Tribble T., Gurley J., Saha S. Left atrial veno-arterial extracorporeal membrane oxygenation case series: a single-center experience. J Surg Res. 2023;281:238–244. doi: 10.1016/j.jss.2022.08.020. [DOI] [PubMed] [Google Scholar]
- 8.Bernhardt A.M., Hillebrand M., Yildirim Y., et al. Percutaneous left atrial unloading to prevent pulmonary oedema and to facilitate ventricular recovery under extracorporeal membrane oxygenation therapy. Interact Cardiovasc Thorac Surg. 2018;26(1):4–7. doi: 10.1093/icvts/ivx266. [DOI] [PubMed] [Google Scholar]
- 9.Bravo C.A., Fried J.A., Willey J.Z., et al. Presence of intracardiac thrombus at the time of left ventricular assist device implantation is associated with an increased risk of stroke and death. J Card Fail. 2021;27(12):1367–1373. doi: 10.1016/j.cardfail.2021.06.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Dogan G., Mariani S., Hanke J.S., et al. Left ventricular assist device implantation in patients with left ventricular thrombus. Artif Organs. 2021;45(9):1006–1013. doi: 10.1111/aor.13963. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Transthoracic Echocardiogram
After return of spontaneous circulation after cardiac arrest, before initiation of extracorporeal membrane oxygenation. Evidence of severe left ventricular dysfunction with chronic apical thrombus.
Transthoracic Echocardiogram
After return of spontaneous circulation after cardiac arrest, before initiation of extracorporeal membrane oxygenation. Evidence of severe left ventricular dysfunction with chronic apical thrombus.
Transthoracic Echocardiogram
After return of spontaneous circulation after cardiac arrest, before initiation of extracorporeal membrane oxygenation. Evidence of severe left ventricular dysfunction with chronic apical thrombus.
Transthoracic Echocardiography
On venoarterial extracorporeal membrane oxygenation support before insertion of a transseptal left atrial cannula for venting. This video demonstrates extensive acute-on-chronic left ventricular thrombus with complete obliteration of the cavity.
Transthoracic Echocardiography
On venoarterial extracorporeal membrane oxygenation support before insertion of a transseptal left atrial cannula for venting. This video demonstrates extensive acute-on-chronic left ventricular thrombus with complete obliteration of the cavity.