Preoperative Stabilization With Left Atrial Venoarterial Extracorporeal Membrane Oxygenation Before Salvage Valve Surgery in Cardiogenic Shock

Patients undergoing salvage cardiac surgery experience markedly elevated mortality, often exceeding the risk predicted by the Society of Thoracic Surgeons Predicted Risk of Mortality score. These patients are typically taken to the operating room while supported by extracorporeal membrane oxygenation (ECMO). In this context, we transitioned from a traditional preoperative mechanical circulatory support strategy using venoarterial ECMO to left atrial venoarterial ECMO (LAVA-ECMO) in patients with cardiogenic shock secondary to valvular dysfunction. We report a single-center, retrospective case series of four high-risk patients with acute severe mitral regurgitation or obstructive aortic stenosis, all with prohibitive Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) scores, who were supported by LAVA-ECMO as a bridge to salvage valve surgery. Left atrial venoarterial-ECMO facilitated hemodynamic stabilization by improving end-organ perfusion and pulmonary decongestion before definitive surgical intervention. All patients survived to hospital discharge, with 0% 30 day mortality despite an extreme predicted operative risk. Our initial experience suggests that LAVA-ECMO may be an effective rescue strategy for patients in cardiogenic shock requiring surgical valve replacement. When combined with a multidisciplinary heart team approach, this cannulation strategy may help improve outcomes in carefully selected patients.