Case Report Awake Extracorporeal Membrane Oxygenation for Very High-Risk Coronary Angioplasty Malek Kass, MD, a Michael Moon, MD, b Minh Vo, MD, a Rohit Singal, MD, b and Amir Ravandi, MD, PhD a a Department of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada b Department of Cardiac Surgery, University of Manitoba, Winnipeg, Manitoba, Canada ABSTRACT High-risk angioplasty has been defined as an intervention on an un- protected left main (LM) coronary artery or “last patent coronary conduit” in the context of moderate to severe left ventricular (LV) dysfunction. We report a case of a patient with severe LV dysfunction, severe aortic valve stenosis, and an occluded right coronary artery requiring elective intervention on a heavily calcified subtotally occluded LM coronary artery while the patient was awake with extracorporeal membrane oxygenation (ECMO) support. Given the added benefit of percutaneous closure, we believe that ECMO support with only conscious sedation is a viable mode of hemodynamic support in high- risk cases. R  ESUM  E L’angioplastie coronarienne à haut risque a  et ed efinie comme une intervention du tronc commun (TC) non prot eg e de l’artère coronaire gauche ou « dernier conduit coronaire  evident » dans le contexte d’une dysfonction ventriculaire gauche (VG) mod er ee à s evère. Nous rapportons le cas d’un patient pr esentant une dysfonction VG s evère, une st enose valvulaire aortique s evère et une occlusion de l’artère coronaire droite n ecessitant une intervention d’urgence sur le TC de l’artère coronaire fortement calcifi ee et partiellement occluse tandis que le patient  etait  eveill e avec l’assistance d’une oxyg enation par membrane extracorpor- elle (ECMO). Compte tenu de l’avantage apport e par la fermeture percutan ee, nous croyons que le soutien de l’ECMO fait avec s edation consciente est un mode viable de soutien h emodynamique dans les cas à haut risque. An 83-year-old man with severe left ventricular (LV) dysfunction (ejection fraction, 25%) and aortic stenosis (AS) (aortic valve area [AVA], 0.6 cm 2 ) presented to the hospital in congestive heart failure. Angiography demonstrated a chronically occluded domi- nant right coronary artery and a subtotally occluded calcified left main (LM) coronary artery (Fig. 1). In discussion with our heart team, we decided to proceed with high-risk percuta- neous intervention (PCI) to the LM coronary artery, followed by consideration for transcatheter aortic valve intervention. The patient agreed to proceed. Case Presentation The patient was brought into the catheterization laboratory and lightly sedated. Access was obtained with 6F sheaths in bilateral femoral veins and arteries. The right femoral artery was closed using 2 6F Perclose ProGlide Suture Mediated Closure Systems (Abbott Vascular, Redwood City, CA) as previously described and upsized to a 17F arterial cannula. The left femoral vein was upsized to a 24/29F 2-stage venous cannula. The patient was placed on ECMO while awake at flow rates of 3 L/min using a BioMedicus 540 centrifugal pump (Medtronic, Minneapolis, MN). The left femoral arterial sheath was upsized to an 8F sheath and, using an 8F VL3.5 guiding catheter, successful PCI was performed with ballooning and stenting of the mid left anterior descending artery (LAD) as well as the LM coronary artery into the LAD. With balloon inflation into the LM coronary artery, there was loss of pulse pressure, and the patient was completely dependent on ECMO support. He tolerated the procedure well with no complications and excellent results (Fig. 2). The arterial cannula was removed with tightening of the Perclose ProGlide Suture Mediated Closure Systems. The 8F arterial sheath was closed with a Perclose device in the usual fashion. The venous cannula was removed with manual hemostasis using the previously described “figure-of-8” suture. 1 The pa- tient was transferred to a nonintensive coronary care unit and discharged 3 days later. Canadian Journal of Cardiology 31 (2015) 227.e11e227.e13 www.onlinecjc.ca Received for publication October 1, 2014. Accepted November 2, 2014. Corresponding author: Dr Malek Kass, Section of Cardiology, University of Manitoba, Y3517-409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada. Tel.: þ1-204-258-1266; fax: þ1-204-233-2157. E-mail: mkass@sbgh.mb.ca See page 227.e13 for disclosure information. http://dx.doi.org/10.1016/j.cjca.2014.11.004 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.