Background
The most severe form of arrhythmia-induced cardiomyopathy in adults— refractory cardiogenic
shock requiring mechanical circulatory support—has rarely been reported.
Objective
The purpose of this study was to describe the management of critically ill patients
admitted for acute, nonischemic, or worsening of previously known cardiac dysfunction
and recent-onset supraventricular arrhythmia who developed refractory cardiogenic
shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO).
Methods
This study is a retrospective analysis of prospectively collected data.
Results
Between 2004 and 2018, 35 patients received VA-ECMO for acute, nonischemic cardiogenic
shock and recent supraventricular arrhythmia (77% atrial fibrillation [AF]). Cardiogenic
shock was the first disease manifestation in 21 patients (60%). Characteristics at
ECMO implantation [median (interquartile range)] were Sequential Organ Failure Assessment
score 10 (7–13); inotrope score 29 (11–80); left ventricular ejection (LVEF) fraction
10% (10%–15%); and lactate level 8 (4–11) mmol/L. For 12 patients, amiodarone and/or
electric cardioversion successfully reduced arrhythmia, improved LVEF, and enabled
weaning off VA-ECMO; 11 had long-term survival without transplantation or long-term
assist device. Eight patients experiencing arrhythmia-reduction failure underwent
ablation procedures (7 atrioventricular node [AVN] with pacing, 1 atrial tachycardia)
and were weaned off VA-ECMO; 7 survived. Of the remaining 15 patients without arrhythmia
reduction or ablation, only the 6 bridged to heart transplantation or left ventricular
(LV) assist device survived.
Conclusion
Arrhythmia-induced cardiomyopathy, mainly AF-related, is an underrecognized cause
of refractory cardiogenic shock and should be considered in patients with nonischemic
cardiogenic shock and recent-onset supraventricular arrhythmia. VA-ECMO support allowed
safe arrhythmia reduction or rate control by AVN ablation while awaiting recovery,
even among those with severe LV dilation.
Keywords
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Article info
Publication history
Published online: March 11, 2021
Footnotes
Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Disclosures: Dr Combes has received lecture fees from Getinge, Baxter, and Xenios. Dr Gandjbakhch has received consulting fees from MicroPort, Medtronic, and Abbott; and educational fees from Boston Scientific. Dr Lebreton has received educational fees from Medtronic, Jarvik, and SynCardia; and lecture fees from Abbott and Medtronic. Dr Leprince has received a research grant from Getinge. Dr Luyt reports consulting fees from Carmat, Thermo Fisher BRAHMS, Faron, and Bayer Healthcare; and lecture fees from Merck and BioMerieux. Dr Schmidt has received lectures fees from Getinge, Xenios, and Drager. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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- Rate-dependent left ventricular filling time: A critical factor for adequate cardiac outputHeart RhythmVol. 18Issue 7
- PreviewIn patients with heart failure and in the elderly, changes in ventricular rate are a major determinant of cardiac output. In these patients, the range of effective ventricular contractions is markedly reduced than in young and normal adults in whom faster heart rates are well tolerated and contribute to increased cardiac output, particularly in conditions characterized by high adrenergic tone. The picture becomes even more complex when atrial fibrillation develops. The loss of atrial contraction, which reduces ventricular filling and the occurrence of left ventricular desynchronization often induced by fast ventricular rates, may result in further deterioration of cardiac function, particularly when ventricular volume is increased and the strength–length relationship is beyond the physiological range.
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