Multiple Bridging: Recovery, Decision, Transplantation, Recovery

Introduction This case describes multiple forms of short term mechanical circulatory support (sMCS) used sequentially in the same patient, and illustrates the role of different clinical goals of sMCS. Case Report A 59 year old man with previous coronary artery bypass surgery attended with troponin positive acute coronary syndrome. After workup, he went for PCI to a native coronary chronic total occlusion using anterograde/retrograde wires. Unfortunately, the left internal mammary graft was dissected, and he suffered cardiac arrest. Day 0: Impella CP as bridge to recover y : During resuscitation an Impella CP was placed via his right femoral artery and resolved circulatory arrest. Further PCI was performed to the LIMA ostium with restoration of flow. He was transferred to ITU. Day 3: Peripheral VA-ECMO as bridge to decision: His clinical status improved, but he remained in shock. His support was upgraded to peripheral veno-arterial (VA) extra-corporeal membrane oxygenation (ECMO), leaving the Impella in place as an LV vent. Day 14: BIVAD as bridge to transplantation: He remained MCS-dependent, and had no absolute contraindications to advanced therapies. He went to theatre for implantation of bilateral short term ventricular assist devices (BI-VAD) to optimise his organ support prior to transplantation. He was placed on the super-urgent waiting list. He had intermittent ventricular fibrillation but continued to mobilise on the ITU. Day 48: Transplantation and bridge to recovery with central ECMO: After 34 days on BIVAD, he underwent orthotopic cardiac transplantation. Due to vasoplegia and RV dysfunction, he was weaned from cardiopulmonary bypass onto central ECMO. Day 50: Weaning support - percutaneous RVAD as bridge to recover y : There was persistent RV dysfunction. Central ECMO was exchanged for a Protek RVAD. Day 56: Explant of RVAD: His status continued to improve. The RVAD was weaned and explanted after 6 days. Day 73: Discharge home: He required intense physiotherapy. After 73 days in hospital he was discharged home. At the time of submission he is alive at 291 days post transplant. Summary This man\u0027s successful outcome was facilitated by judicious use of sMCS, on each occasion with a clear strategy in mind. Surgically implanted and percutaneous modes were used. Collaboration between cardiologists, intensivists and cardiac surgeons was essential to facilitate optimal care.