Correspondence On-site ECMO in the cardiac intensive care unit. A new tool to improve advanced cardiopulmonary resuscitation Carolina Devesa-Cordero ⁎, Iago Sousa-Casasnovas, Miriam Juárez-Fernández, Fernando Sarnago-Cebada, Felipe Díez-delHoyo, Edwin Gómez-Tadeo, Manuel Martínez-Sellés, Francisco Fernández-Avilés Department of Cardiology, Hospital General Universitario Gregorio Marañon, Madrid, Spain article info Article history: Received 15 December 2015 Accepted 3 January 2016 Available online 6 January 2016 Keywords: ECMO Extracorporeal-CPR Stent thrombosis A 53 year old man, active tobacco, had an out of hospital cardiac ar- rest (OHCA) due to a ventricular fibrillation. He was transferred to our centre after resuscitation that included five defibrillations, orotracheal intubation and all the usual intravenous drugs. Return of spontaneous circulation (ROSC) was achieved after 25 min. The electrocardiogram showed ST-segment elevation in the anterior and inferior leads (Fig. 1A). On arrival at the catheterization laboratory (cath-lab) the patient presented an invasive blood pressure of 80/50 mm Hg and norepineph- rine infusion was started at 0.2 mcg/kg/min. Coronary angiography was performed via right femoral artery, showing a subtotal acute thrombotic lesion in proximal right coronary artery, as well as left anterior descend- ing artery chronic occlusion with heterocoronary collateral circulation from right coronary artery. A drug eluting stent was placed in the prox- imal segment of the right coronary artery with successful angiographic result (Fig. 1B and C). Revascularization of left anterior descending was attempted but failed. Ten minutes after admission to the cardiac intensive care unit, the patient developed cardiac arrest due to ventricular fibrillation that recurred immediately after each defibrillation. Advanced cardiopulmo- nary resuscitation was initiated and prolonged for 50 min. Due to refractory cardiac arrest, a decision was made to initiate extracorporeal membrane oxygenation (ECMO), by the cath-lab, for car- diopulmonary life support with veno-arterial ECMO device CARDIOHELP ® (Maquet, Germany) (Fig. 2A). The procedure was performed at the bed- side by the cath-lab team. A peripheral veno-arterial ECMO access was ob- tained using the Seldinger technique, guided by vascular ultrasound, inserting a 15 French (F) arterial cannula (Maquet, Germany) through the left femoral artery and a 21 F through right femoral vein. Circula- tory support was started progressively, reaching 2.7 l/min and venous sat- uration of 63% with no pulsatility on the arterial pressure monitoring. The patient was transferred back to the cath-lab, where the suspected stent thrombosis was confirmed. The opening of the right coronary artery was achieved with the implantation of two stents, re- storing the normal flow (Fig. 2B and C). At the end of the procedure an intra-aortic balloon pump (IABP) was placed and the proper position of the cannula was confirmed. Upon returning to the CICU, ECMO pump flow was set at 2.7 L/min plus IABP on 1:1. During the first hours pulsatility was recovered, nor- epinephrine was decreased and stopped and dobutamine infusion (8 mcg/kg/min) was started in addition to nitroprusside, maintaining mean arterial pressure of 70 mm Hg. Urgent echocardiogram showed severe left ventricle dysfunction. In the following days partial improvement in ventricular func- tion (LVEF 0.4) was documented, allowing initiation of the weaning from ECMO. The patient was taken off ECMO support on the 5th day. Decannulation was performed by peripheral vascular surgeons, with reparation of the femoral artery. IABP was removed on the 6th day, the patient was extubated on the 9th day, and the subsequent evo- lution of the patient was favorable without neurological sequelae. Finally he could be discharged after 20 days of admission. ECMO is a temporary support of heart and lung function by partial cardiopulmonary bypass. Blood is drained from right atrium to an exter- nal pump which pushes the blood through a membrane gas exchanger and a warmer, then it returns to the aorta. Percutaneous approach is possible for the peripheral cannulation using the Seldinger technique. The latter option makes ECMO an attractive support in the cath-lab, as a trained interventional cardiologist can place the ECMO in few minutes [1,2]. Although there are no data from randomized studies to support the routine use of ECMO, in case series and observational studies the use of ECMO for in-hospital and out-of-hospital cardiac arrest has been associ- ated with improved survival when compared with conventional in pa- tients b 75 years old with potentially correctable conditions. In settings where it can be rapidly implemented, ECPR may be considered for select patients for whom the suspected etiology of the cardiac arrest is International Journal of Cardiology 207 (2016) 3–5 ⁎ Corresponding author at: Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, Dr. Esquerdo 46, 28047-Madrid, Spain. E-mail address: carolina.devesa.cordero@gmail.com (C. Devesa-Cordero). http://dx.doi.org/10.1016/j.ijcard.2016.01.050 0167-5273/© 2016 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard