This document describes the case of a 67-year-old man in progressive cardiogenic shock following a myocardial infarction. He underwent subclavian intra-aortic balloon pump placement followed by peripheral veno-arterial extracorporeal life support due to worsening shock. The combination of intra-aortic balloon pump counterpulsation and extracorporeal life support support stabilized the patient, allowing successful bridge to permanent left ventricular assist device placement three days later. The case highlights the multidisciplinary approach and graded medical and mechanical circulatory support needed to manage refractory cardiogenic shock as a bridge to destination therapy.

1. Subclavian Intra-Aortic Balloon Pump Followed by
Peripheral Veno-Arterial Extra-Corporeal Life
Support Prior to Surgical Left Ventricular Assist
Device in a Patient with Recent Myocardial
Infarction and Progressive Circulatory Collapse:
Two Bridges and a Destination
Elizabeth Retzer, MD
Sandeep Nathan, MD, MSc
University of Chicago Medicine
Chicago, IL

2. Elizabeth M. Retzer, MD
I/we have no real or apparent conflicts of interest to report.

3. Clinical presentation
67 year old man with ischemic
cardiomyopathy (EF 25%) presents
with progressive dyspnea,
confusion, acute on chronic renal
failure and refractory hypotension.
Recent history of MI/cardiogenic
shock requiring inotropic and
balloon pump support, complicated
by respiratory failure and
ischemia/gangrene to right foot.
Other co-morbidities
• Peripheral Arterial
Disease
• Chronic Kidney
Disease
• Multiple prior MIs
• Recent DES implants
• Paroxysmal AFib
• History of prostate CA
• Malnutrition

4. Hospital Course:
Refractory Cardiogenic Shock
• Started on Milrinone for inotropic support
• Brief initial improvement, followed by progressive decline (increasing
lactate, decreased systemic perfusion, shock)
• Pressors (dopamine, norephinephrine) initiated
• Increasing frequency of tachyarrhythmias (atrial fib, NSVT)
• Spiraling hemodynamics / progressive hypoperfusion / multi-organ failure
ensued despite extensive support with vasoactive medications
Key clinical considerations:
• Progressive shock state
• PAD precluding large-bore arterial access with ongoing R foot
ischemia following prior arterial cannulation
• No residual ischemic/viable myocardium
• Not a cardiac transplant candidate (for a variety of reasons)

5. IABP Placement: Subclavian Approach
Raman et al. Ann Thorac Surg 2010;90:1032-4
• Given the extensive co-morbidities and
clear need for additional hemodynamic
support pending a decision on
destination-LVAD therapy, the decision
was made to proceed with a right
subclavian IABP.
• This was performed without
complications in the OR using a limited
cut-down and synthetic graft
anastomosed to the RSCA with
fashioning of a hemostatic valve through
which a Maquet 7.5 Fr. IABP was placed
into the descending aorta

6. Hospital Course Continued:
Following IABP Placement
• Continued patient decompensation:
• Increasing pressor requirement despite IABP
• Worsening tachyarrythmias during which there was
no IABP augmentation
• Worsening perfusion (increasing lactate, decreasing
SVO2)
• Decision made to initiate percutaneous extracorporeal
life support [V-A ECLS (ECMO)] after extensive
discussion between Interventional Cardiology,
Cardiothoracic Surgery and Heart Failure / Transplant

7. ECMO Cannula Placement:
Femoral Approach with Antegrade Sheath
Antegrade 6 Fr Arrow sheath
in SFA for limb perfusion
15 Fr arterial cannula
(Medtronic BioMedicus)
21 Fr venous cannula
(Medtronic BioMedicus)
Extracorporeal life support (ECLS) was initiated in the
cardiac cath lab using the Maquet CardioHelp system
and peripherally placed cannulae.

8. Counterpulsation with ECMO & IABP
IABP Console Maquet Cardiohelp ECLS Console
Decision was made to leave subclavian IABP in place for coronary
perfusion while circulatory / oxygenation support was provided
by ECLS circuit.

9. IABP on Hold: Complete Loss of
Intrinsic Cardiac Pulsatility
IABP Console ICU Monitoring Screen

10. Hospital Course Continued:
Improvement on Combined Therapy
• Perfusion parameters begin improving with
combination IABP and ECLS
• Decreasing lactate
• Improving renal function, urine output without
diuretic support
• Vasoactive medications slowly able to be weaned off
• With increasing stability, patient able to receive
permanent LVAD (Thoratec HeartMate II) on post-ECLS
day 3

11. Summary
• Multiple medical / surgical considerations in the
management of refractory cardiogenic shock
• Graded medical / mechanical support as a bridge to
destination therapy
• Successful combined use of subclavian IABP and
peripheral ECLS with prophylactic antegrade limb
perfusion.
• Collaboration between Interventional Cardiology,
Cardiothoracic Surgery and Heart Failure/
Transplantation Services
• Successful bridge to destination LVAD