Use of extracorporeal membrane oxygenation for mechanical circulatory support in a patient with 5-fluorouracil induced acute heart failure.

E xtracorporeal life support has evolved to become a viable support option in patients with acute cardiac failure. Tailored mechanical circulatory support (MCS) can now be provided to patients using existing extracorporeal life support devices. 1 We report the successful use of peripheral venoarte-rial extracorporeal membrane oxygenation (ECMO) to provide MCS to a patient with acute 5-flurouracil (5-FU)–induced car-diomyopathy. 5-FU is a key component of adjuvant chemo-therapy for colorectal cancer. It is also frequently used in the treatment of gastric, esophageal, pancreatic, breast, bladder, and prostate cancer. There is a wide range of cardiotoxicity with this 5-FU, including ischemia, vasospasm, arrhythmia, hyper-tension, Q-T interval prolongation, and acute cardiomyopathy and 5-FU–induced cardiac complications are not rare. 2 This case illustrates the crucial place of ECMO as a bridge to recovery in chemotherapy, cardiomyopathy, or decision making. A 32-year-old man began adjuvant treatment for colorectal adenocarcinoma with 5-FU continuous infusion after presumed curative bowel resection. He experienced stuttering chest pain from day 1 of therapy with progressive shortness of breath. His risk factors for cardiovascular disease included a positive family history of ischemic heart disease and previous methamphetamine use. He presented to the emergency department in a peripheral hospital on completion of his first cycle, where he was noted to be in paroxysmal atrial fibrillation with rapid ventricular response alternating with sinus tachycardia with inferolateral ST elevation. Cardiac troponin was mildly elevated and a presumptive diagnosis of 5-FU–induced car-diotoxicity was made. Sublingual glyceryl trinitrate, oral aten-olol, and amlodipine were administered. After this, the patient became hypotensive, with cool and clammy peripheries. He was commenced on dobutamine and noradrenaline infusions and transferred to our center. Urgent cardiac catheterization confirmed angiographically normal coronary arteries (Figure 1). His left ventricular end-diastolic pressure was elevated at 30 mm Hg. An intra-aortic balloon pump was inserted through the left femoral artery. Transthoracic echocardiogram revealed severe global dys-function with an ejection fraction of 10% to 15% with normal valves and no pericardial effusion. There was no evidence of significant dilation or thinning of ventricular chambers, thus inferring an acute and potentially reversible process (Figure 2). The patient was transferred to the intensive care unit with severe cardiogenic shock despite intra-aortic balloon counter-pulsation and high doses of dobutamine (10 μg/kg per minute), noradrenaline (0.25 μg/kg per minute), and adrenaline (0.25 μg/kg per minute). There was evidence of end-organ malperfusion with increasing lactate, altered mentation, and early hepatic and renal …