Heart rhythm | 2021
Arrhythmia-induced cardiomyopathy: a potentially reversible cause of refractory cardiogenic shock requiring veno-arterial Extracorporeal Membrane Oxygenation.
Abstract
BACKGROUND\nThe most severe form of arrhythmia-induced cardiomyopathy in adults- refractory cardiogenic shock requiring mechanical circulatory support-has rarely been reported.\n\n\nOBJECTIVE\nTo 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-ECMO (VA-ECMO).\n\n\nMETHODS\nThis study is a retrospective analysis of prospectively collected data.\n\n\nRESULTS\nBetween 2004 and 2018, 35 patients received VA-ECMO for acute, nonischemic cardiogenic shock and recent supraventricular arrhythmia (77% atrial fibrillation). Cardiogenic shock was the first disease manifestation in 21 (60%) patients. Characteristics at ECMO implantation (median [IQR]) were: SOFA 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 with pacing and 1 atrial tachycardia) were weaned-off VA-ECMO; 7 survived. Among the remaining 15 patients without arrhythmia reduction or ablation, only the 6 bridged to heart transplantation or left ventricular assist device survived.\n\n\nCONCLUSION\nArrhythmia-induced cardiomyopathy, mainly atrial fibrillation-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 atrioventricular-node ablation while awaiting recovery, even among those with severe left ventricular dilation.