Aortic regurgitation and extracorporeal membrane oxygenation: An undiscussed topic

This is the case of a young male admitted to the hospital for acute cardiac failure in chronic dilated cardiomyopathy due to aortic regurgitation (AR): the patient had previously refused aortic valve replacement (AVR) for the fear of postoperative outcome. He suffered from ongoing dyspnea and peripheral edema with a serious asthenia. Clinical conditions were poor with seriously impaired biventricular function (ejection fraction of about 10%-15% and moderate dilation of the right ventricle with TAPSE of about 12 mm) associated to severe AR and pulmonary edema. The question was: what could we do? Surgery, “watch and see” or biventricular support? The AVR could have been affected by high mortality rate for the risk of failure of the extracorporeal circulation weaning; the “watch and see” approach could have been inadequate for the hemodynamic instability (systolic pressure of about 90 mmHg, low urine output, impaired consciousness due to low cardiac output, increase of lactates) and for the young age of the patient; the biventricular support was considered with several criticism for the severe AR. The possibility to unload the left ventricle by the use of trans-atrial vent was disqualified because the entity of regurgitant volume was higher than the drainable entity allowed. The patient was then treated by mechanical ventilation and amine infusion (Dobutamine 7.5 毺g/Kg/ min and adrenaline about 0,2 毺g/Kg/min): despite intensive medical treatment the patient died three days later. We know that severe AR is a clear contraindication for ventricular support but what can we affirm about mild or moderate AR. Moreover, what is the best management in case of acute dysfunction due to severe AR? In the series presented in literature, there are no information about the entity of AR[1] and this topic has been discussed mainly in the field of left ventricular assist devices[2-6] where the aortic valve dysfunction is frequent in long term follow up[7The aim of this short discussion is to open the question of the AR in case of ECMO implantation. This is the case of a young male admitted to the hospital for acute cardiac failure in chronic dilated cardio-myopathy due to aortic regurgitation (AR): the patient had previously refused aortic valve replacement (AVR) for the fear of postoperative outcome. Further studies are required to assess this topic and the perspectives to increase the use of the peripheral ECMO and the percutaneous ventricular venting through the interatrial septum may be of interest to improve the outcome of such ill patients. Journal of Acute Disease (2012)68-69