Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation (LAVA-ECMO) is a Feasible Option for Patients in Cardiogenic Shock for Whom Impella Offloading is Contraindicated

Introduction Left ventricular thrombus is a potentially life-threatening condition with significant risk of catastrophic embolic events. We present a case of a young patient with cardiogenic shock and biventricular thrombi salvaged by utilizing left atrial veno-arterial extracorporeal membrane oxygenation (LAVA-ECMO). Case Report A 20-year-old male presented with acute biventricular cardiogenic shock with progressive end organ injury. An echocardiogram revealed a left ventricular ejection fraction of 10% with biventricular apical thrombi. The multidisciplinary Shock Team recommended further support with VA-ECMO. However, VA-ECMO alone increases afterload and possibly worsens ventricular distention, potentially leading to stasis, thrombus development, and pulmonary edema. An Impella device is often used to decompress the ventricle; however, it was contraindicated in this patient due to the left ventricular thrombus. Therefore, the decision was made to offload the left ventricle using a left atrial catheter placed percutaneously via the common femoral vein, with transseptal access to the left atrium for cannulation of LAVA-ECMO. This multistage catheter allowed both atria to be drained simultaneously, unloading both ventricles of the heart. Ultimately, the patient was deemed not to be a candidate for transplant due to obesity. He was transitioned to a Heartmate 3 durable left ventricular assist device (LVAD) on hospital day 6, with concurrent insertion of a Sentinel embolic protection device—with multiple captured debris upon removal— and surgical removal of the thrombi. He remained neurologically intact postoperatively and was discharged home after 21 days in the hospital. He was diagnosed with a familial cardiomyopathy with plans for weight loss and cardiac transplantation. Summary Biventricular thrombosis is a rare finding in a patient with profound cardiogenic shock, which complicates treatment options. LAVA-ECMO can provide biventricular support without the need for intraventricular device placement and should be considered early in the course of this disease.