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Arrhythmia-induced cardiomyopathy: A potentially reversible cause of refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation

  • Guillaume Hékimian
    Correspondence
    Address reprint requests and correspondence: Dr Guillaume Hékimian, Service de Médecine Intensive Réanimation, Institute of Cardiology, Groupe Hospitalier Pitié–Salpêtrière, 47, bd de l’Hôpital, 75651 Paris Cedex 13, France.
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Nicolas Paulo
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Xavier Waintraub
    Affiliations
    Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France
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  • Nicolas Bréchot
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Matthieu Schmidt
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Guillaume Lebreton
    Affiliations
    Department of Cardiac and Thoracic Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France
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  • Marc Pineton de Chambrun
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Grégoire Muller
    Affiliations
    Intensive Care Unit, Hôpital d’Orléans, Orléans, France
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  • Guillaume Franchineau
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Simon Bourcier
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Ania Nieszkowska
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Paul Masi
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Pascal Leprince
    Affiliations
    Department of Cardiac and Thoracic Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France
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  • Alain Combes
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
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  • Estelle Gandjbakhch
    Affiliations
    Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France
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  • Charles-Edouard Luyt
    Affiliations
    Service de Médecine Intensive Réanimation, Institute of Cardiology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié–Salpêtrière, Paris, France

    UPMC Université Paris 06, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
    Search for articles by this author

      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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      Linked Article

      • Rate-dependent left ventricular filling time: A critical factor for adequate cardiac output
        Heart RhythmVol. 18Issue 7
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          In 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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