Riad Akkari, MD
Critical Care Fellow
George Washington University
Laurel, MD
Disclosure information not submitted.
Robert Markie, RN
ECMO Coordinator
George Washington University Hospital, United States
Disclosure information not submitted.
David Yamane, BS, MD
Assistant Professor of Emergency Medicine, Anesthesiology, and Critical Care Medicine
George Washington University Hospital, United States
Disclosure information not submitted.
Mustafa Al-mashat, MD
Assistant professor
George Washington University, United States
Disclosure information not submitted.
Title: ECPR and ECPELLA in the resuscitation of WPW cardiac arrest.
Case Report Body:
Introduction: Wolff-Parkinson-White (WPW) syndrome is characterized by a broad spectrum of clinical conditions ranging from asymptomatic to paroxysmal episodes of atrioventricular tachycardia. Extracorporeal cardiopulmonary resuscitation (ECPR) incorporates extracorporeal membrane oxygenation (ECMO) along with cardiopulmonary resuscitation (CPR), which has been shown to have benefits in out-of-hospital atrioventricular tachyarrhythmia. We present the case of WPW cardiac arrest that was resuscitated using ECPR.
Description: Our patient is a 25-year-old male with otherwise no medical comorbidities who presented a witnessed arrest in the field receiving bystander CPR. EMS achieved ROSC after two rounds of CPR and defibrillation. The patient was intubated for airway protection and started on vasoactive agents for vascular support. The initial EKG revealed concerns for WPW syndrome, echocardiographic showed severe global hypokinesis with biventricular failure, and the Laboratory work was significant for severe lactic acidosis of 5.6 mmol/L. The diagnosis of cardiogenic shock was established, and hence he was started on inotropic support with epinephrine. Despite escalating levels of chemical support, his course was complicated by PEA cardiac arrest requiring repeated resuscitation. With ongoing instability without clear etiology, the decision was made to proceed with VA-ECMO cannulation for ECPR support emergently. In lieu of the poor cardiac function, an Impella device was placed for assistance with left ventricular unloading while allowing time for recovery. Over the next 48 hours, the patients’ lactic acidosis resolved with the resolution of shock state. The patient was decannulated from ECMO support on hospital day 4, the left ventricular assist device was removed on hospital day 5, and he then received successful ablation of the rapidly conducting accessory pathway that was thought to be the cause of his initial arrest. The patient was then extubated with intact neurological function.
Discussion: ECPR is a novel rescue therapy that has been noted to decrease mortality in out-of-hospital atrioventricular tachyarrhythmias. It can be used in combination with a left ventricular assist device to provide further cardiac support while awaiting recovery in reversible conditions.