Six-Day Extreme Challenge: Can ECMO with Axillary Artery Cannulation Truly Reduce Cardiac Afterload? A Case Report A Case Report and minireview

Six-Day Extreme Challenge: Can ECMO with Axillary Artery Cannulation Truly Reduce Cardiac Afterload? 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A Case Report A Case Report and minireview Zhou-xing Zhang, Xiao-Kang Zeng, Chen-hui Qiu, Wei Hu, Ying Zhu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4972978/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective The use of axillary artery cannulation in extracorporeal membrane oxygenation (ECMO) for patients with cardiogenic shock is gaining traction due to its potential to reduce cardiac afterload. However, clinical outcomes often diverge from theoretical expectations. This article presents a case study of a patient who experienced cardiac arrest and initiated veno-arterial ECMO (V-A ECMO) support 2 hours and 40 minutes after undergoing cardiopulmonary resuscitation (CPR). Despite ECMO intervention, the patient's aortic valve remained closed for up to six days. Transitioning from femoral to axillary artery cannulation did not yield a marked improvement in cardiac afterload. In the absence of abilities for atrial septostomy, conservative management was implemented, ultimately resulting in the normalization of aortic valve function and the patient's regained consciousness. This article seeks to examine the potential benefits and limitations of axillary artery cannulation in the context of ECMO for cardiogenic shock. Methods Following prolonged CPR, the patient experienced severe myocardial dysfunction and an impaired ability to open the aortic valve. The transition from femoral to axillary artery cannulation did not result in a significant reduction in cardiac afterload. However, through the optimization of ECMO parameters, intra-aortic balloon pump (IABP) support, improved fluid management, and tailored anticoagulation therapy, the patient’s cardiac function gradually recovered. Results After six days of therapeutic interventions, the patient's aortic valve function returned to normal, and consciousness was restored. cardiopulmonary resuscitation cardiogenic shock VA-ECMO axillary artery intra-aortic balloon pump Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Cardiac arrest is a life-threatening condition that demands immediate and effective intervention to sustain the patient’s vital functions[ 1 ]. In such emergencies, extracorporeal membrane oxygenation (ECMO) is widely employed as a critical method of cardiac support, ensuring continuous oxygenation and circulation[ 2 ]. However, a common and challenging complication during ECMO is inadequate cardiac contraction, which may hinder the proper opening of the aortic valve. This dysfunction exacerbates the burden on the cardiopulmonary system and significantly heightens the risk of thrombosis. Addressing insufficient cardiac contraction and aortic valve dysfunction promptly is therefore essential for enhancing patient survival and recovery. Traditionally, ECMO is initiated using femoral artery cannulation. While axillary artery cannulation is theorized to reduce cardiac afterload, its clinical efficacy remains debated[ 3 ]. This article presents a case involving a cardiac arrest patient who experienced inadequate cardiac contraction and a closed aortic valve under ECMO support. Despite transitioning from femoral to axillary artery cannulation, there was no significant reduction in cardiac afterload. Without the ability for atrial septostomy, the medical team pursued conservative measures, including optimizing ECMO parameters, utilizing intra-aortic balloon pump (IABP) support, improving fluid management, and adjusting anticoagulation therapy. These interventions gradually led to the restoration of the patient’s cardiac function. By examining this case in detail, the article aims to provide valuable insights for clinical decision-making and treatment strategies in similar scenarios, ultimately improving patient outcomes. Case Report Patient Information and History The patient, a 52-year-old male worker, had experienced chest tightness for over six months, with a noticeable worsening in the two days prior to his admission on July 31, 2022, at 14:32, to the North Campus of Hangzhou First People's Hospital. He reported no significant medical history, smoking, or drinking habits. During the initial consultation, the patient suddenly experienced cardiac and respiratory arrest, necessitating immediate cardiopulmonary resuscitation (CPR) and endotracheal intubation. Bedside echocardiography revealed a dilated right heart and compressed left heart, consistent with the "D" sign, indicative of a pulmonary embolism. Immediate resuscitation efforts, including urokinase thrombolysis, were initiated. After 2 hours and 40 minutes of CPR, ECMO support was established, and the patient was transferred to the Lakeside Campus of Hangzhou First People's Hospital for further management. Upon admission, the patient required ventilator-assisted ventilation (PA mode: FiO₂ 40%, PEEP 15 cmH₂O, PC 12 cmH₂O, f 12 breaths/min) and ECMO support (pump speed 3615 rpm, blood flow 3.98 L/min, gas flow 7.5 L/min, FiO₂ 100%). ECG monitoring showed a heart rate of 130 bpm, blood pressure of 128/98 mmHg, respiratory rate of 18 breaths/min, and unmeasurable oxygen saturation. Physical examination revealed pupils measuring 0.6 cm with no light response, cold extremities, and the presence of bloody secretions in the airway and gastric drainage fluid. The initial arterial blood gas analysis indicated a pH of 7.35, K⁺ 2.44 mmol/L, Ca²⁺ 0.707 mmol/L, Lac 17 mmol/L, HB 11.5 g/dL, and oxygen delivery of 631 ml/(min·m²). Laboratory tests revealed a white blood cell count of 23.2×10⁹/L, hemoglobin level of 11.5 g/dL, platelet count of 174×10⁹/L, and C-reactive protein (CRP) < 0.1 mg/L. Biochemistry results showed ALT 414 U/L, AST 1367 U/L, albumin 30.8 g/L, potassium 2.65 mmol/L, LDH 846 U/L, serum creatinine (Scr) 146 µmol/L, BUN 8.91 mmol/L, and procalcitonin (PCT) 0.45 ng/mL. Cardiac enzyme levels were elevated, with CK 10191 U/L, CKMB 1156 U/L, troponin I (TNI) > 80 µg/L, and BNP 61.6 pg/mL. Coagulation tests indicated a prothrombin time (PT) of 25 seconds, an unmeasurable activated partial thromboplastin time (APTT), INR 2.25, fibrinogen 0.89 g/L, and D-dimer 17140 µg/L. The electrocardiogram showed atrial fibrillation with accelerated ventricular rhythm (bigeminy), incomplete right bundle branch block, abnormal Q waves in leads I, II, III, avF, V4-V6, and low voltage (Fig. 1 A). Bedside ultrasound revealed thickening of the left ventricular wall and septum with diffuse hypokinesis, atrial enlargement, left ventricular dysfunction with an ejection fraction (EF) of 20%, aortic valve non-opening, and no blood flow in VTI (Fig. 1 B). The admission diagnoses were as follows: 1) Post-cardiac arrest resuscitation and post-ECMO status, 2) Cardiogenic shock, 3) Suspected pulmonary embolism, 4) Suspected acute myocardial infarction, 5) Acute respiratory failure, 6) Hypoxic-ischemic encephalopathy, 7) Pulmonary edema, 8) Metabolic acidosis, 9) Hyperlactatemia, 10) Hypokalemia, 11) Hypoproteinemia, 12) Liver dysfunction, 13) Gastrointestinal bleeding, 14) Coagulation dysfunction, 15) Acute renal failure, 16) Pulmonary infection, 17) Septic shock, and 18) Arrhythmia: supraventricular tachycardia. Initial Treatment A comprehensive treatment plan was meticulously devised and executed to address the primary clinical issues. Key interventions included active plasma and protein supplementation, alongside aggressive fluid resuscitation, to stabilize vital signs. Anti-inflammatory therapy was administered using methylprednisolone succinate (Milrone) at 80 mg Q12H to mitigate myocardial edema. Atorvastatin, dosed at 20 mg QD, was employed to stabilize arterial plaques. To prevent complications, the intra-aortic balloon pump (IABP) was considered to alleviate left ventricular load caused by aortic valve closure, and distal arterial bypass grafting was performed to enhance peripheral perfusion. Given contraindications to anticoagulation, management of airway and gastrointestinal bleeding involved the administration of blood products, acid suppression, and hemostasis using omeprazole (Nexium) at 80 mg Q12H, supplemented by somatostatin at 6 mg QD. Organ support measures included mild hypothermia for neuroprotection, mannitol 40 g Q8H to reduce intracranial pressure, and sedation to decrease oxygen demand, with close monitoring of cerebral blood flow dynamics. Renal support was provided via bedside continuous renal replacement therapy (CRRT). Empirical anti-infective therapy was initiated with piperacillin-tazobactam at 4.5 g Q8H and vancomycin at 1 g Q12H, coupled with vigilant monitoring of inflammatory markers and cultures, allowing for timely adjustments to the regimen. Three hours post-admission, arterial blood gas analysis revealed significant improvements in pH, arteriovenous carbon dioxide pressure difference (Pv-aCO₂), central venous oxygen saturation (ScvO₂), and a nearly 50% lactate clearance rate within three hours (Fig. 2 ). Nevertheless, due to the extended duration of cardiopulmonary resuscitation (CPR), the patient's cardiac function remained critically impaired, with the aortic valve still in a closed state. Following the stabilization of circulation, further evaluation of the chest pain triad was planned to elucidate the underlying etiology. Unfortunately, the precise cause of respiratory and cardiac arrest could not be determined due to suboptimal imaging quality and the constraints imposed by extracorporeal membrane oxygenation (ECMO) support therapy. Choice of Axillary Artery Cannulation During the first three days post-admission, the patient’s vital signs were highly unstable, complicated by episodes of malignant arrhythmias and severe tissue leakage. The ECMO flow rates were erratic and difficult to control. To stabilize the patient’s condition, we implemented aggressive fluid resuscitation, made continuous adjustments to ECMO flow rates, titrated norepinephrine and epinephrine doses, and temporarily administered amiodarone. By the fourth day, the patient’s vital signs had stabilized, although the aortic valve remained non-functional. Given the potential for increased afterload associated with femoral artery cannulation, we elected to transition the ECMO return pathway from the femoral to the axillary artery, guided by transesophageal echocardiography. The axillary artery cannulation was successfully executed, resulting in improved hemodynamic parameters; however, there was no significant reduction in cardiac afterload, and the aortic valve remained closed (Fig. 3 ). Conservative Treatment Measures Due to technical constraints at our hospital, an atrial septostomy (ASD) could not be performed. Consequently, we adopted a series of conservative treatment measures. We identified three primary factors contributing to the persistent closure of the aortic valve: severe left heart failure, elevated ECMO flow rate, and excessive vascular volume load. To address these issues while maintaining circulatory stability, We enhance fluid negative balance to reduce cardiac preload, while aiming for MAP ≥ 65mmHg to lower cardiac afterload. (Fig. 4 ). Additionally, ECMO flow and mean arterial pressure (MAP) were carefully adjusted to decrease cardiac afterload, and inotropic support with epinephrine and dobutamine was continued. Intra-aortic balloon pump (IABP) support was sustained to further reduce cardiac afterload. Anticoagulant therapy was actively modified, with regular monitoring of coagulation parameters to prevent thrombosis and ensure ECMO patency. Following these interventions, on the sixth day, the patient's aortic valve could still be opened even with IABP closed (Fig. 5 ). By the eighth day, the patient’s cardiac contractile function had gradually improved, the aortic valve was functioning normally, consciousness was regained, and the patient resumed oral intake. Treatment Outcomes Despite initial progress, ongoing challenges such as a persistently low ejection fraction and increased pulmonary exudates necessitated a tracheostomy, chest drainage, and continued anti-infective therapy. Ultimately, due to financial constraints, the family opted to withdraw ECMO support, leading to the patient’s discharge against medical advice. Discussion Insufficient cardiac contraction in patients experiencing cardiac arrest under ECMO support presents a complex therapeutic challenge. Common strategies for left ventricular decompression include optimizing ECMO parameters, utilizing an intra-aortic balloon pump (IABP), administering positive inotropic and vasodilator agents, performing atrial septostomy, facilitating pulmonary venous drainage, and employing devices like Impella[ 4 ]. Although axillary artery cannulation in ECMO theoretically reduces cardiac afterload, its clinical efficacy may not always meet expectations. This approach is particularly advantageous for patients with limited groin access, peripheral vascular disease, or post-heart transplant failure. However, its precise impact on cardiac afterload necessitates further investigation. In the absence of atrial septostomy, favorable outcomes can still be achieved through conservative measures, including ECMO optimization, IABP, enhanced fluid management, and anticoagulation. 1. ECMO Support in Cardiac Arrest Patients: ECMO serves as a temporary life support system for patients with severely compromised cardiopulmonary function, effectively replacing partial or complete heart and lung function through an extracorporeal circulation system. Early initiation of ECMO in patients experiencing cardiac arrest has been demonstrated to significantly enhance prognosis[ 5 ]. However, the management of insufficient cardiac contractility during ECMO support remains a significant challenge, necessitating a multifaceted treatment approach. 2. Causes and Clinical Impact of Aortic Valve Closure: Insufficient cardiac contraction during ECMO support can result in the aortic valve failing to open properly, a condition typically arising from severe myocardial damage. In such cases, the heart is unable to overcome the resistance of the aortic valve, leading to obstructed blood flow. This not only exacerbates the burden on the heart and lungs but also significantly increases the risk of thrombosis. Additionally, the failure of the aortic valve to open elevates left ventricular pressure and myocardial oxygen consumption, further straining the heart, increasing pulmonary exudates, impairing oxygenation, and leading to inadequate organ perfusion. Therefore, timely resolution of these complications is essential for improving patient survival and recovery rates. 3. Comparison of Axillary and Femoral Artery Cannulation: Currently, femoral artery-femoral vein cannulation is the most commonly used vascular access for VA-ECMO[ 6 ]. However, the hemodynamic characteristics of femoral-femoral VA-ECMO, including retrograde perfusion, can lead to increased left ventricular afterload, elevated left ventricular filling pressures, pulmonary edema, and complications such as North-South syndrome, as well as extensive thrombosis within the left ventricle[ 7 – 9 ]. Femoral artery cannulation also carries risks of lower limb ischemia, bleeding, and catheter site infection[ 10 , 11 ]. Axillary artery cannulation is often chosen for patients with limited groin access, peripheral vascular disease, or post-heart transplant failure[ 3 ]. VA-ECMO via axillary artery cannulation can provide antegrade blood flow perfusion, theoretically reducing cardiac afterload and avoiding the side effects of femoral-femoral VA-ECMO. However, its actual effect in clinical practice remains controversial, with significant variation in its effectiveness in reducing cardiac afterload among different patients[ 12 ]. In patients with extremely poor cardiac function, axillary artery cannulation may not significantly reduce afterload, necessitating the combination of other auxiliary treatments. 4. Limitations of Atrial Septostomy: Atrial septostomy (ASD) is known to reduce cardiac afterload by lowering left atrial pressure[ 13 ]. However, due to technical constraints, ASD was not feasible in this case, necessitating the exploration of alternative conservative treatment strategies. In this instance, a significant reduction in cardiac afterload was achieved through the optimization of ECMO parameters, the implementation of intra-aortic balloon pump (IABP) therapy, advanced fluid management, and targeted anticoagulation therapy. These interventions demonstrated the efficacy of conservative approaches in managing cardiac afterload. 5. Implementation and Adjustment of Treatment Strategies: Enhancing cardiac contractile function necessitates a multifaceted therapeutic approach. First, it is crucial to optimize ECMO parameters, particularly blood flow and oxygen delivery. Second, the administration of positive inotropic agents, such as norepinephrine and epinephrine, should be employed to augment myocardial contractility. The intra-aortic balloon pump (IABP) enhances diastolic coronary perfusion, reduces systolic cardiac afterload, improves cardiac function, and facilitates aortic valve opening. Furthermore, meticulous management of fluid balance, nutritional support, infection control, and organ function is essential for stabilizing the patient’s overall condition and fostering cardiac recovery. Following comprehensive adjustments to the treatment regimen, the patient’s aortic valve opened on the sixth day, accompanied by improvements in organ function and relevant clinical markers (Fig. 6 ). It is also important to acknowledge the potential contribution of spontaneous myocardial recovery, given the patient’s six-day hospitalization, to the observed aortic valve opening. 6. Importance of Multidisciplinary Collaboration: Throughout the treatment process (Fig. 7 ), close collaboration among emergency physicians, radiologists, ultrasound specialists, intensivists, and vascular surgeons was essential. The multidisciplinary team integrated diverse professional perspectives to devise the optimal treatment plan, swiftly addressed potential complications, and significantly enhanced both the patient’s survival prospects and recovery outcomes. Conclusion Active and timely management of complications in patients with cardiogenic shock supported by VA-ECMO is essential. When cardiac function is severely compromised and the aortic valve remains closed, axillary artery cannulation for ECMO may not substantially reduce cardiac afterload, particularly when atrial septostomy (ASD) is not feasible due to technical constraints. Nevertheless, favorable outcomes can still be achieved through conservative measures, such as optimizing ECMO parameters, employing an intra-aortic balloon pump (IABP), improving fluid management, and administering anticoagulation therapy. This case underscores the importance of selecting appropriate adjunctive therapies tailored to the specific clinical scenario to enhance patient prognosis in cardiogenic shock. Declarations Clinical trial number: not applicable. Ethical Approval For our article, we have got the written approval of participants and obtained rapid approval from the Ethics Committee of Hangzhou First People’s Hospital. Competing interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Authors' contributions Zhou-xing Zhang: He played a leading role in this study. He is responsible for data collection and analysis, as well as writing research methods, results, and discussion sections. Xiao-Kang Zeng& Chen-hui Qiu: He played an important role in the research. He collects data and provides important insights in the discussion section of his research. Wei Hu& Ying Zhu: He played a key role in the research. He participated in the interpretation and discussion of the research results. In addition, the third author is also responsible for organizing and compiling relevant literature reviews for the study, providing important background support for the research. Jing Yang: She has made valuable contributions to the research. she actively participated in data collection, conducted detailed analysis of the data, and provided important viewpoints and insights in the interpretation and discussion of the results. In addition, she was responsible for revising and editing the overall structure and language to ensure the accuracy and readability of the research. Funding The Construction Fund of Medical Key Disciplines of Hangzhou (Grant: OO20200485). Availability of data and materials all of the material is owned by the authors and/or no permissions are required. References Schnaubelt S, Krammel M. PULS - Austrian Cardiac Arrest Awareness Association: An overview of a multi-tiered and multi-facetted regional initiative to save lives. Resusc Plus. 2023;15:100453. El Sibai R, Bachir R, El Sayed M. ECMO use and mortality in adult patients with cardiogenic shock: a retrospective observational study in U.S. hospitals. BMC Emerg Med. 2018;18(1):20. Radwan M, Baghdadi K, Popov AF, Sandoval Boburg R, Risteski P, Schlensak C, Walter T, Berger R, Emrich F. Right Axillary Artery Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Postcardiotomy Patients: A Single-Center Experience. Med (Kaunas) 2023, 59(11). Ezad SM, Ryan M, Donker DW, Pappalardo F, Barrett N, Camporota L, Price S, Kapur NK, Perera D. Unloading the Left Ventricle in Venoarterial ECMO: In Whom, When, and How? Circulation. 2023;147(16):1237–50. Yannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosmopoulos M, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807–16. Le Gall A, Follin A, Cholley B, Mantz J, Aissaoui N, Pirracchio R. Veno-arterial-ECMO in the intensive care unit: From technical aspects to clinical practice. Anaesth Crit Care Pain Med. 2018;37(3):259–68. Cai J, Abudou H, Chen Y, Wang H, Wang Y, Li W, Li D, Niu Y, Chen X, Liu Y, et al. The effects of ECMO on neurological function recovery of critical patients: A double-edged sword. Front Med (Lausanne). 2023;10:1117214. Distelmaier K, Wiedemann D, Lampichler K, Toth D, Galli L, Haberl T, Steinlechner B, Heinz G, Laufer G, Lang IM, et al. Interdependence of VA-ECMO output, pulmonary congestion and outcome after cardiac surgery. Eur J Intern Med. 2020;81:67–70. Weber C, Deppe AC, Sabashnikov A, Slottosch I, Kuhn E, Eghbalzadeh K, Scherner M, Choi YH, Madershahian N, Wahlers T. Left ventricular thrombus formation in patients undergoing femoral veno-arterial extracorporeal membrane oxygenation. Perfusion. 2018;33(4):283–8. Woodward EL, Shen T, Ramsay JG. Suspected Lower Extremity Ischemia After End-to-Side Femoral Arterial Grafting for VA-ECMO. J Cardiothorac Vasc Anesth. 2021;35(6):1824–9. Roberts SH, Schumer EM, Sullivan M, Grotberg J, Jenkins B, Fischer I, Damiano M, Schill MR, Masood MF, Kotkar K, et al. Percutaneous decannulation reduces procedure length and rates of groin wound infection in patients on venoarterial extracorporeal membrane oxygenation. JTCVS Open. 2024;18:80–6. Chiarini G, Mariani S, Schaefer AK, van Bussel BCT, Di Mauro M, Wiedemann D, Saeed D, Pozzi M, Botta L, Boeken U, et al. Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study. Crit Care. 2024;28(1):265. Katamreddy A, Snipelisky DF, Eleid MF. Atrial Septostomy as a Bridge to Replace a Thrombosed Mechanical Aortic Valve Requiring Extracorporeal Membrane Oxygenation. J Heart Valve Dis. 2016;25(5):644–7. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4972978","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":347228994,"identity":"8c8c15af-b8c2-4aa4-a808-7da7fea63758","order_by":0,"name":"Zhou-xing Zhang","email":"","orcid":"","institution":"1.\tFourth Clinical Medical College of Zhejiang Chinese Medical University, Zhejiang Hangzhou 310006, China.","correspondingAuthor":false,"prefix":"","firstName":"Zhou-xing","middleName":"","lastName":"Zhang","suffix":""},{"id":347228997,"identity":"74249e59-0cf9-4880-84ad-e2b6a7b297d8","order_by":1,"name":"Xiao-Kang Zeng","email":"","orcid":"","institution":"Affiliated Hangzhou First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiao-Kang","middleName":"","lastName":"Zeng","suffix":""},{"id":347228999,"identity":"4a0a8b1e-d45d-453d-9fb9-ea0fef8319c9","order_by":2,"name":"Chen-hui Qiu","email":"","orcid":"","institution":"Affiliated Hangzhou First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chen-hui","middleName":"","lastName":"Qiu","suffix":""},{"id":347229001,"identity":"f9d74d0a-5301-4456-9abe-5dee01e77e51","order_by":3,"name":"Wei Hu","email":"","orcid":"","institution":"Affiliated Hangzhou First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Hu","suffix":""},{"id":347229003,"identity":"84649728-45ca-4bac-a757-9fb53615b7cc","order_by":4,"name":"Ying Zhu","email":"","orcid":"","institution":"Affiliated Hangzhou First People’s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Zhu","suffix":""},{"id":347229004,"identity":"8bd8b306-0375-4839-bf77-3762345d60af","order_by":5,"name":"Jing Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIie3PPWsCQRCA4ZGFtRly7YhiutQbBEUQ/Ct7HFy1CZZXWBxc8Aq/Wv0XlilXhE2Ktbc0VaoUdopgQmrFPTuLfep5mRkAz7tDPJh+Hw+nDnbzbLmVSd+dPJCFKvC4JtBEYmuNO6mD+k9WHUHqqfL1xgocBmvd6CHDFimehCmHIB/K6wmbyGhGHNujH7MJ32tAdr1wbNFCo0CEj9d4E1oOgl5ciXxOURKCVs1eOGBFEtVgqAWKT9WEYgmZuDRPJVZGJiJpDTp/eZxmBnbpbzcoZ8vdPunXg3x8PTmDt417nud5F/0B9mhH/o7uG0gAAAAASUVORK5CYII=","orcid":"","institution":"Affiliated Hangzhou First People’s Hospital","correspondingAuthor":true,"prefix":"","firstName":"Jing","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2024-08-25 13:44:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4972978/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4972978/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66856013,"identity":"09cd3202-9d57-48ce-bd08-1dc8b26c1a72","added_by":"auto","created_at":"2024-10-17 07:49:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":835948,"visible":true,"origin":"","legend":"\u003cp\u003eThe electrocardiogram and bedside ultrasound.\u003c/p\u003e\n\u003cp\u003eA. The electrocardiogram showed atrial fibrillation with accelerated ventricular rhythm (bigeminy), incomplete right bundle branch block, abnormal Q waves in leads I, II, III, avF, V4-V6, and low voltage. B. Bedside ultrasound revealed thickening of the left ventricular wall and septum with diffuse hypokinesis, atrial enlargement, left ventricular dysfunction with an ejection fraction (EF) of 20%, aortic valve non-opening, and no blood flow in VTI (Figure 1B).\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-4972978/v1/46877b8ba5b540fe1d28b795.png"},{"id":66857648,"identity":"f4e45d1b-eef2-4c15-afbc-78efd714bdac","added_by":"auto","created_at":"2024-10-17 07:57:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":311385,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe trends in blood gas analysis of patients after 7 days admission to the Intensive Care Unit and during Extracorporeal Membrane Oxygenation support.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-4972978/v1/8682456997de4d18aa085df3.png"},{"id":66858188,"identity":"67117b55-4018-4ad5-8355-46d939385a89","added_by":"auto","created_at":"2024-10-17 08:05:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":476532,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTransition the ECMO return pathway from the femoral to the axillary artery, guided by transesophageal echocardiography.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. Schematic diagram of axillary artery catheterization. B. After axillary artery catheterization, X-ray examination of the catheter position.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-4972978/v1/e2e8e36fde8c6eeaa41a26b9.png"},{"id":66856011,"identity":"2bd2ca8d-da69-421b-bc13-6aa7ebd5b35a","added_by":"auto","created_at":"2024-10-17 07:49:36","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":72220,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWe enhance fluid negative balance to reduce cardiac preload and try to lower cardiac afterload. (Figure 4)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. We enhance fluid negative balance through CRRT to reduce cardiac preload.\u003c/p\u003e\n\u003cp\u003eB. After negative balance, the CVP curve of the patient shows a downward trend.\u003c/p\u003e\n\u003cp\u003eC. Targeting MAP ≥ 65mmHg to reduce cardiac afterload.\u003c/p\u003e\n\u003cp\u003eD. After adjusting the blood pressure target, the patient's Vasoactive-inotropic score curve showed a downward trend.\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-4972978/v1/b15e80a40a52f78e72b329c5.png"},{"id":66857650,"identity":"fd316174-587b-49c7-88df-61b57e149791","added_by":"auto","created_at":"2024-10-17 07:57:36","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":954477,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAfter treatment adjustment, on the sixth day, the patient's aortic valve could still be opened even with IABP closed.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA. On the parasternal longitudinal section, it can be seen that the aortic valve can be opened.\u003c/p\u003e\n\u003cp\u003eB. On the apical five chamber view, it can be seen that the aortic valve can be opened.\u003c/p\u003e\n\u003cp\u003eC. When IABP is turned off, arterial waveforms can be seen.\u003c/p\u003e","description":"","filename":"image5.png","url":"https://assets-eu.researchsquare.com/files/rs-4972978/v1/52dd973804c303d87653d428.png"},{"id":66857651,"identity":"a80c58a6-98b2-41c5-b3c1-af7987e15630","added_by":"auto","created_at":"2024-10-17 07:57:36","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":577254,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe trend of changes in various organ related indicators of patients after entering the intensive care unit and during extracorporeal membrane oxygenation support.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image6.png","url":"https://assets-eu.researchsquare.com/files/rs-4972978/v1/0de5721844b1103b820cfdde.png"},{"id":66856015,"identity":"c4eda3d4-e270-4ea4-b202-72d030eff52a","added_by":"auto","created_at":"2024-10-17 07:49:36","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":569906,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe treatment process and adjustment of treatment strategies for the patient after admission to the icu.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"image7.png","url":"https://assets-eu.researchsquare.com/files/rs-4972978/v1/de9460a54fd0336bd186b911.png"},{"id":66860385,"identity":"d9cf5336-1e47-4b75-b871-f1a9d57eb9c5","added_by":"auto","created_at":"2024-10-17 08:21:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4964407,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4972978/v1/01e66dc5-e404-473f-b517-2484b29ad326.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Six-Day Extreme Challenge: Can ECMO with Axillary Artery Cannulation Truly Reduce Cardiac Afterload? A Case Report A Case Report and minireview","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCardiac arrest is a life-threatening condition that demands immediate and effective intervention to sustain the patient\u0026rsquo;s vital functions[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In such emergencies, extracorporeal membrane oxygenation (ECMO) is widely employed as a critical method of cardiac support, ensuring continuous oxygenation and circulation[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, a common and challenging complication during ECMO is inadequate cardiac contraction, which may hinder the proper opening of the aortic valve. This dysfunction exacerbates the burden on the cardiopulmonary system and significantly heightens the risk of thrombosis. Addressing insufficient cardiac contraction and aortic valve dysfunction promptly is therefore essential for enhancing patient survival and recovery.\u003c/p\u003e \u003cp\u003eTraditionally, ECMO is initiated using femoral artery cannulation. While axillary artery cannulation is theorized to reduce cardiac afterload, its clinical efficacy remains debated[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This article presents a case involving a cardiac arrest patient who experienced inadequate cardiac contraction and a closed aortic valve under ECMO support. Despite transitioning from femoral to axillary artery cannulation, there was no significant reduction in cardiac afterload. Without the ability for atrial septostomy, the medical team pursued conservative measures, including optimizing ECMO parameters, utilizing intra-aortic balloon pump (IABP) support, improving fluid management, and adjusting anticoagulation therapy. These interventions gradually led to the restoration of the patient\u0026rsquo;s cardiac function. By examining this case in detail, the article aims to provide valuable insights for clinical decision-making and treatment strategies in similar scenarios, ultimately improving patient outcomes.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Information and History\u003c/h2\u003e \u003cp\u003eThe patient, a 52-year-old male worker, had experienced chest tightness for over six months, with a noticeable worsening in the two days prior to his admission on July 31, 2022, at 14:32, to the North Campus of Hangzhou First People's Hospital. He reported no significant medical history, smoking, or drinking habits. During the initial consultation, the patient suddenly experienced cardiac and respiratory arrest, necessitating immediate cardiopulmonary resuscitation (CPR) and endotracheal intubation. Bedside echocardiography revealed a dilated right heart and compressed left heart, consistent with the \"D\" sign, indicative of a pulmonary embolism. Immediate resuscitation efforts, including urokinase thrombolysis, were initiated. After 2 hours and 40 minutes of CPR, ECMO support was established, and the patient was transferred to the Lakeside Campus of Hangzhou First People's Hospital for further management.\u003c/p\u003e \u003cp\u003eUpon admission, the patient required ventilator-assisted ventilation (PA mode: FiO₂ 40%, PEEP 15 cmH₂O, PC 12 cmH₂O, f 12 breaths/min) and ECMO support (pump speed 3615 rpm, blood flow 3.98 L/min, gas flow 7.5 L/min, FiO₂ 100%). ECG monitoring showed a heart rate of 130 bpm, blood pressure of 128/98 mmHg, respiratory rate of 18 breaths/min, and unmeasurable oxygen saturation. Physical examination revealed pupils measuring 0.6 cm with no light response, cold extremities, and the presence of bloody secretions in the airway and gastric drainage fluid. The initial arterial blood gas analysis indicated a pH of 7.35, K⁺ 2.44 mmol/L, Ca\u0026sup2;⁺ 0.707 mmol/L, Lac 17 mmol/L, HB 11.5 g/dL, and oxygen delivery of 631 ml/(min\u0026middot;m\u0026sup2;). Laboratory tests revealed a white blood cell count of 23.2\u0026times;10⁹/L, hemoglobin level of 11.5 g/dL, platelet count of 174\u0026times;10⁹/L, and C-reactive protein (CRP)\u0026thinsp;\u0026lt;\u0026thinsp;0.1 mg/L. Biochemistry results showed ALT 414 U/L, AST 1367 U/L, albumin 30.8 g/L, potassium 2.65 mmol/L, LDH 846 U/L, serum creatinine (Scr) 146 \u0026micro;mol/L, BUN 8.91 mmol/L, and procalcitonin (PCT) 0.45 ng/mL. Cardiac enzyme levels were elevated, with CK 10191 U/L, CKMB 1156 U/L, troponin I (TNI)\u0026thinsp;\u0026gt;\u0026thinsp;80 \u0026micro;g/L, and BNP 61.6 pg/mL. Coagulation tests indicated a prothrombin time (PT) of 25 seconds, an unmeasurable activated partial thromboplastin time (APTT), INR 2.25, fibrinogen 0.89 g/L, and D-dimer 17140 \u0026micro;g/L. The electrocardiogram showed atrial fibrillation with accelerated ventricular rhythm (bigeminy), incomplete right bundle branch block, abnormal Q waves in leads I, II, III, avF, V4-V6, and low voltage (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Bedside ultrasound revealed thickening of the left ventricular wall and septum with diffuse hypokinesis, atrial enlargement, left ventricular dysfunction with an ejection fraction (EF) of 20%, aortic valve non-opening, and no blood flow in VTI (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe admission diagnoses were as follows: 1) Post-cardiac arrest resuscitation and post-ECMO status, 2) Cardiogenic shock, 3) Suspected pulmonary embolism, 4) Suspected acute myocardial infarction, 5) Acute respiratory failure, 6) Hypoxic-ischemic encephalopathy, 7) Pulmonary edema, 8) Metabolic acidosis, 9) Hyperlactatemia, 10) Hypokalemia, 11) Hypoproteinemia, 12) Liver dysfunction, 13) Gastrointestinal bleeding, 14) Coagulation dysfunction, 15) Acute renal failure, 16) Pulmonary infection, 17) Septic shock, and 18) Arrhythmia: supraventricular tachycardia.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eInitial Treatment\u003c/h2\u003e \u003cp\u003eA comprehensive treatment plan was meticulously devised and executed to address the primary clinical issues. Key interventions included active plasma and protein supplementation, alongside aggressive fluid resuscitation, to stabilize vital signs. Anti-inflammatory therapy was administered using methylprednisolone succinate (Milrone) at 80 mg Q12H to mitigate myocardial edema. Atorvastatin, dosed at 20 mg QD, was employed to stabilize arterial plaques. To prevent complications, the intra-aortic balloon pump (IABP) was considered to alleviate left ventricular load caused by aortic valve closure, and distal arterial bypass grafting was performed to enhance peripheral perfusion.\u003c/p\u003e \u003cp\u003eGiven contraindications to anticoagulation, management of airway and gastrointestinal bleeding involved the administration of blood products, acid suppression, and hemostasis using omeprazole (Nexium) at 80 mg Q12H, supplemented by somatostatin at 6 mg QD. Organ support measures included mild hypothermia for neuroprotection, mannitol 40 g Q8H to reduce intracranial pressure, and sedation to decrease oxygen demand, with close monitoring of cerebral blood flow dynamics. Renal support was provided via bedside continuous renal replacement therapy (CRRT). Empirical anti-infective therapy was initiated with piperacillin-tazobactam at 4.5 g Q8H and vancomycin at 1 g Q12H, coupled with vigilant monitoring of inflammatory markers and cultures, allowing for timely adjustments to the regimen.\u003c/p\u003e \u003cp\u003eThree hours post-admission, arterial blood gas analysis revealed significant improvements in pH, arteriovenous carbon dioxide pressure difference (Pv-aCO₂), central venous oxygen saturation (ScvO₂), and a nearly 50% lactate clearance rate within three hours (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Nevertheless, due to the extended duration of cardiopulmonary resuscitation (CPR), the patient's cardiac function remained critically impaired, with the aortic valve still in a closed state. Following the stabilization of circulation, further evaluation of the chest pain triad was planned to elucidate the underlying etiology. Unfortunately, the precise cause of respiratory and cardiac arrest could not be determined due to suboptimal imaging quality and the constraints imposed by extracorporeal membrane oxygenation (ECMO) support therapy.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eChoice of Axillary Artery Cannulation\u003c/h2\u003e \u003cp\u003eDuring the first three days post-admission, the patient\u0026rsquo;s vital signs were highly unstable, complicated by episodes of malignant arrhythmias and severe tissue leakage. The ECMO flow rates were erratic and difficult to control. To stabilize the patient\u0026rsquo;s condition, we implemented aggressive fluid resuscitation, made continuous adjustments to ECMO flow rates, titrated norepinephrine and epinephrine doses, and temporarily administered amiodarone. By the fourth day, the patient\u0026rsquo;s vital signs had stabilized, although the aortic valve remained non-functional. Given the potential for increased afterload associated with femoral artery cannulation, we elected to transition the ECMO return pathway from the femoral to the axillary artery, guided by transesophageal echocardiography. The axillary artery cannulation was successfully executed, resulting in improved hemodynamic parameters; however, there was no significant reduction in cardiac afterload, and the aortic valve remained closed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eConservative Treatment Measures\u003c/h2\u003e \u003cp\u003eDue to technical constraints at our hospital, an atrial septostomy (ASD) could not be performed. Consequently, we adopted a series of conservative treatment measures. We identified three primary factors contributing to the persistent closure of the aortic valve: severe left heart failure, elevated ECMO flow rate, and excessive vascular volume load. To address these issues while maintaining circulatory stability, We enhance fluid negative balance to reduce cardiac preload, while aiming for MAP\u0026thinsp;\u0026ge;\u0026thinsp;65mmHg to lower cardiac afterload. (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Additionally, ECMO flow and mean arterial pressure (MAP) were carefully adjusted to decrease cardiac afterload, and inotropic support with epinephrine and dobutamine was continued. Intra-aortic balloon pump (IABP) support was sustained to further reduce cardiac afterload. Anticoagulant therapy was actively modified, with regular monitoring of coagulation parameters to prevent thrombosis and ensure ECMO patency. Following these interventions, on the sixth day, the patient's aortic valve could still be opened even with IABP closed (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). By the eighth day, the patient\u0026rsquo;s cardiac contractile function had gradually improved, the aortic valve was functioning normally, consciousness was regained, and the patient resumed oral intake.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eTreatment Outcomes\u003c/h2\u003e \u003cp\u003eDespite initial progress, ongoing challenges such as a persistently low ejection fraction and increased pulmonary exudates necessitated a tracheostomy, chest drainage, and continued anti-infective therapy. Ultimately, due to financial constraints, the family opted to withdraw ECMO support, leading to the patient\u0026rsquo;s discharge against medical advice.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eInsufficient cardiac contraction in patients experiencing cardiac arrest under ECMO support presents a complex therapeutic challenge. Common strategies for left ventricular decompression include optimizing ECMO parameters, utilizing an intra-aortic balloon pump (IABP), administering positive inotropic and vasodilator agents, performing atrial septostomy, facilitating pulmonary venous drainage, and employing devices like Impella[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although axillary artery cannulation in ECMO theoretically reduces cardiac afterload, its clinical efficacy may not always meet expectations. This approach is particularly advantageous for patients with limited groin access, peripheral vascular disease, or post-heart transplant failure. However, its precise impact on cardiac afterload necessitates further investigation. In the absence of atrial septostomy, favorable outcomes can still be achieved through conservative measures, including ECMO optimization, IABP, enhanced fluid management, and anticoagulation.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e1. ECMO Support in Cardiac Arrest Patients:\u003c/h2\u003e \u003cp\u003eECMO serves as a temporary life support system for patients with severely compromised cardiopulmonary function, effectively replacing partial or complete heart and lung function through an extracorporeal circulation system. Early initiation of ECMO in patients experiencing cardiac arrest has been demonstrated to significantly enhance prognosis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, the management of insufficient cardiac contractility during ECMO support remains a significant challenge, necessitating a multifaceted treatment approach.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2. Causes and Clinical Impact of Aortic Valve Closure:\u003c/h2\u003e \u003cp\u003eInsufficient cardiac contraction during ECMO support can result in the aortic valve failing to open properly, a condition typically arising from severe myocardial damage. In such cases, the heart is unable to overcome the resistance of the aortic valve, leading to obstructed blood flow. This not only exacerbates the burden on the heart and lungs but also significantly increases the risk of thrombosis. Additionally, the failure of the aortic valve to open elevates left ventricular pressure and myocardial oxygen consumption, further straining the heart, increasing pulmonary exudates, impairing oxygenation, and leading to inadequate organ perfusion. Therefore, timely resolution of these complications is essential for improving patient survival and recovery rates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3. Comparison of Axillary and Femoral Artery Cannulation:\u003c/h2\u003e \u003cp\u003eCurrently, femoral artery-femoral vein cannulation is the most commonly used vascular access for VA-ECMO[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the hemodynamic characteristics of femoral-femoral VA-ECMO, including retrograde perfusion, can lead to increased left ventricular afterload, elevated left ventricular filling pressures, pulmonary edema, and complications such as North-South syndrome, as well as extensive thrombosis within the left ventricle[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Femoral artery cannulation also carries risks of lower limb ischemia, bleeding, and catheter site infection[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Axillary artery cannulation is often chosen for patients with limited groin access, peripheral vascular disease, or post-heart transplant failure[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. VA-ECMO via axillary artery cannulation can provide antegrade blood flow perfusion, theoretically reducing cardiac afterload and avoiding the side effects of femoral-femoral VA-ECMO. However, its actual effect in clinical practice remains controversial, with significant variation in its effectiveness in reducing cardiac afterload among different patients[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In patients with extremely poor cardiac function, axillary artery cannulation may not significantly reduce afterload, necessitating the combination of other auxiliary treatments.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4. Limitations of Atrial Septostomy:\u003c/h2\u003e \u003cp\u003eAtrial septostomy (ASD) is known to reduce cardiac afterload by lowering left atrial pressure[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, due to technical constraints, ASD was not feasible in this case, necessitating the exploration of alternative conservative treatment strategies. In this instance, a significant reduction in cardiac afterload was achieved through the optimization of ECMO parameters, the implementation of intra-aortic balloon pump (IABP) therapy, advanced fluid management, and targeted anticoagulation therapy. These interventions demonstrated the efficacy of conservative approaches in managing cardiac afterload.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e5. Implementation and Adjustment of Treatment Strategies:\u003c/h2\u003e \u003cp\u003eEnhancing cardiac contractile function necessitates a multifaceted therapeutic approach. First, it is crucial to optimize ECMO parameters, particularly blood flow and oxygen delivery. Second, the administration of positive inotropic agents, such as norepinephrine and epinephrine, should be employed to augment myocardial contractility. The intra-aortic balloon pump (IABP) enhances diastolic coronary perfusion, reduces systolic cardiac afterload, improves cardiac function, and facilitates aortic valve opening. Furthermore, meticulous management of fluid balance, nutritional support, infection control, and organ function is essential for stabilizing the patient\u0026rsquo;s overall condition and fostering cardiac recovery. Following comprehensive adjustments to the treatment regimen, the patient\u0026rsquo;s aortic valve opened on the sixth day, accompanied by improvements in organ function and relevant clinical markers (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). It is also important to acknowledge the potential contribution of spontaneous myocardial recovery, given the patient\u0026rsquo;s six-day hospitalization, to the observed aortic valve opening.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e6. Importance of Multidisciplinary Collaboration:\u003c/h2\u003e \u003cp\u003eThroughout the treatment process (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e), close collaboration among emergency physicians, radiologists, ultrasound specialists, intensivists, and vascular surgeons was essential. The multidisciplinary team integrated diverse professional perspectives to devise the optimal treatment plan, swiftly addressed potential complications, and significantly enhanced both the patient\u0026rsquo;s survival prospects and recovery outcomes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eActive and timely management of complications in patients with cardiogenic shock supported by VA-ECMO is essential. When cardiac function is severely compromised and the aortic valve remains closed, axillary artery cannulation for ECMO may not substantially reduce cardiac afterload, particularly when atrial septostomy (ASD) is not feasible due to technical constraints. Nevertheless, favorable outcomes can still be achieved through conservative measures, such as optimizing ECMO parameters, employing an intra-aortic balloon pump (IABP), improving fluid management, and administering anticoagulation therapy. This case underscores the importance of selecting appropriate adjunctive therapies tailored to the specific clinical scenario to enhance patient prognosis in cardiogenic shock.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor our article, we have got the written approval of participants and obtained rapid approval from the Ethics Committee of Hangzhou First People’s Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eZhou-xing Zhang:\u003c/strong\u003e He played a leading role in this study. He is responsible for data collection and analysis, as well as writing research methods, results, and discussion sections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eXiao-Kang Zeng\u0026amp;\u003c/strong\u003e \u003cstrong\u003eChen-hui Qiu:\u003c/strong\u003e He played an important role in the research. He collects data and provides important insights in the discussion section of his research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWei Hu\u0026amp;\u003c/strong\u003e \u003cstrong\u003eYing Zhu:\u003c/strong\u003e He played a key role in the research. He participated in the interpretation and discussion of the research results. In addition, the third author is also responsible for organizing and compiling relevant literature reviews for the study, providing important background support for the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJing Yang:\u0026nbsp;\u003c/strong\u003eShe has made valuable contributions to the research. she actively participated in data collection, conducted detailed analysis of the data, and provided important viewpoints and insights in the interpretation and discussion of the results. In addition, she was responsible for revising and editing the overall structure and language to ensure the accuracy and readability of the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Construction Fund of Medical Key Disciplines\u0026nbsp;of Hangzhou (Grant: OO20200485).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eall of the material is owned by the authors and/or no permissions are required.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchnaubelt S, Krammel M. PULS - Austrian Cardiac Arrest Awareness Association: An overview of a multi-tiered and multi-facetted regional initiative to save lives. Resusc Plus. 2023;15:100453.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Sibai R, Bachir R, El Sayed M. ECMO use and mortality in adult patients with cardiogenic shock: a retrospective observational study in U.S. hospitals. BMC Emerg Med. 2018;18(1):20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadwan M, Baghdadi K, Popov AF, Sandoval Boburg R, Risteski P, Schlensak C, Walter T, Berger R, Emrich F. Right Axillary Artery Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in Postcardiotomy Patients: A Single-Center Experience. Med (Kaunas) 2023, 59(11).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEzad SM, Ryan M, Donker DW, Pappalardo F, Barrett N, Camporota L, Price S, Kapur NK, Perera D. Unloading the Left Ventricle in Venoarterial ECMO: In Whom, When, and How? Circulation. 2023;147(16):1237\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYannopoulos D, Bartos J, Raveendran G, Walser E, Connett J, Murray TA, Collins G, Zhang L, Kalra R, Kosmopoulos M, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST): a phase 2, single centre, open-label, randomised controlled trial. Lancet. 2020;396(10265):1807\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe Gall A, Follin A, Cholley B, Mantz J, Aissaoui N, Pirracchio R. Veno-arterial-ECMO in the intensive care unit: From technical aspects to clinical practice. Anaesth Crit Care Pain Med. 2018;37(3):259\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCai J, Abudou H, Chen Y, Wang H, Wang Y, Li W, Li D, Niu Y, Chen X, Liu Y, et al. The effects of ECMO on neurological function recovery of critical patients: A double-edged sword. Front Med (Lausanne). 2023;10:1117214.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDistelmaier K, Wiedemann D, Lampichler K, Toth D, Galli L, Haberl T, Steinlechner B, Heinz G, Laufer G, Lang IM, et al. Interdependence of VA-ECMO output, pulmonary congestion and outcome after cardiac surgery. Eur J Intern Med. 2020;81:67\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeber C, Deppe AC, Sabashnikov A, Slottosch I, Kuhn E, Eghbalzadeh K, Scherner M, Choi YH, Madershahian N, Wahlers T. Left ventricular thrombus formation in patients undergoing femoral veno-arterial extracorporeal membrane oxygenation. Perfusion. 2018;33(4):283\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoodward EL, Shen T, Ramsay JG. Suspected Lower Extremity Ischemia After End-to-Side Femoral Arterial Grafting for VA-ECMO. J Cardiothorac Vasc Anesth. 2021;35(6):1824\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoberts SH, Schumer EM, Sullivan M, Grotberg J, Jenkins B, Fischer I, Damiano M, Schill MR, Masood MF, Kotkar K, et al. Percutaneous decannulation reduces procedure length and rates of groin wound infection in patients on venoarterial extracorporeal membrane oxygenation. JTCVS Open. 2024;18:80\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiarini G, Mariani S, Schaefer AK, van Bussel BCT, Di Mauro M, Wiedemann D, Saeed D, Pozzi M, Botta L, Boeken U, et al. Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study. Crit Care. 2024;28(1):265.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatamreddy A, Snipelisky DF, Eleid MF. Atrial Septostomy as a Bridge to Replace a Thrombosed Mechanical Aortic Valve Requiring Extracorporeal Membrane Oxygenation. J Heart Valve Dis. 2016;25(5):644\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cardiopulmonary resuscitation, cardiogenic shock, VA-ECMO, axillary artery, intra-aortic balloon pump","lastPublishedDoi":"10.21203/rs.3.rs-4972978/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4972978/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe use of axillary artery cannulation in extracorporeal membrane oxygenation (ECMO) for patients with cardiogenic shock is gaining traction due to its potential to reduce cardiac afterload. However, clinical outcomes often diverge from theoretical expectations. This article presents a case study of a patient who experienced cardiac arrest and initiated veno-arterial ECMO (V-A ECMO) support 2 hours and 40 minutes after undergoing cardiopulmonary resuscitation (CPR). Despite ECMO intervention, the patient's aortic valve remained closed for up to six days. Transitioning from femoral to axillary artery cannulation did not yield a marked improvement in cardiac afterload. In the absence of abilities for atrial septostomy, conservative management was implemented, ultimately resulting in the normalization of aortic valve function and the patient's regained consciousness. This article seeks to examine the potential benefits and limitations of axillary artery cannulation in the context of ECMO for cardiogenic shock.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFollowing prolonged CPR, the patient experienced severe myocardial dysfunction and an impaired ability to open the aortic valve. The transition from femoral to axillary artery cannulation did not result in a significant reduction in cardiac afterload. However, through the optimization of ECMO parameters, intra-aortic balloon pump (IABP) support, improved fluid management, and tailored anticoagulation therapy, the patient\u0026rsquo;s cardiac function gradually recovered.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAfter six days of therapeutic interventions, the patient's aortic valve function returned to normal, and consciousness was restored.\u003c/p\u003e","manuscriptTitle":"Six-Day Extreme Challenge: Can ECMO with Axillary Artery Cannulation Truly Reduce Cardiac Afterload? A Case Report A Case Report and minireview","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-17 07:49:31","doi":"10.21203/rs.3.rs-4972978/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"23e37768-760c-4a0e-ab12-f5265b10f9c2","owner":[],"postedDate":"October 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-17T07:49:34+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-17 07:49:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4972978","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4972978","identity":"rs-4972978","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}