Mechanical circulatory support (MCS) has significantly transformed the management of patients with end-stage heart failure and cardiogenic shock. These technologies offer life-saving options, serving as bridges to decision or transplantation. A staged triple-bridge approach employing consecutive MCS devices is a less common but potentially life-saving strategy for managing severe hemodynamic instability. This report details the successful use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO), durable left ventricular assist device (LVAD), and temporary right ventricular assist device (RVAD) to stabilize a patient with cardiogenic shock for heart transplantation listing, illustrating the efficacy and challenges of this approach.
A 52-year-old woman presented to our hospital with acute decompensated dilated cardiomyopathy and cardiogenic shock SCAI C and INTERMACS II. This was the first manifestation of heart failure, and she had not received any heart failure treatment in the past. Her medical history also included fibroelastosis endocardium diagnosed in childhood, treated with digoxin, arterial hypertension, hypothyroidism, panic disorder, and a family history of cardiac disease. Upon admission, the patient exhibited severe symptoms, including shortness of breath, profound fatigue, and NYHA Class IV heart failure. Initial echocardiography showed a dilated left ventricle, severely reduced ejection fraction (10%), significant mitral regurgitation, moderate tricuspid regurgitation, moderate dysfunction of the right ventricle and elevated central venous pressure. Emergency mechanical circulatory support with VA-ECMO was initiated on 27.10.2024 for hemodynamic stabilization. Peripheral femoral cannulation was performed under imaging guidance using the Seldinger technique. An arterial cannula 15F was inserted as well as an antegrade 6F perfusion cannula. VA-ECMO provided effective stabilization, allowing temporary discontinuation of high-dose inotropic support. However, the patient’s clinical status necessitated long-term circulatory support, and she was indicated for the implantation of a durable LVAD.
On 28.10.2024, the patient underwent implantation of a HeartMate 3 (HM 3, Abbott Laboratories, Abbott Park, IL) LVAD via median sternotomy. The inflow cannula was positioned at the left ventricular apex, and the outflow graft was anastomosed to the ascending aorta. Postoperatively, LVAD flows were maintained at 2.6–3.0 l/min, providing adequate support. However, the patient developed persistent right ventricular dysfunction, necessitating the implantation of a temporary RVAD CentriMag (Abbot Vascular, Santa Clara, California) on 29.10.2024. Transesophageal echocardiography showed right ventricular dilatation (right ventricular end-diastolic diameter 44 mm), shift of the interventricular septum to the right with nearly obliterated left ventricle and severe tricuspid valve regurgitation. The inflow cannula was inserted into the right atrium, and the outflow cannula was anastomosed to the pulmonary artery through a graft.
The patient remained on dual mechanical support for 9 days, during which her right ventricular function gradually improved. The RVAD was successfully weaned and explanted on 7.11.2024. Despite these interventions, her postoperative course was complicated by acute kidney injury, managed conservatively with diuretics and electrolyte correction, and respiratory compromise due to bilateral pleural effusions, requiring repeated thoracentesis and diuresis. She also developed Candida glabrata and Klebsiella pneumoniae infections, which were treated with antifungal and targeted antibiotic therapy.
The patient required prolonged mechanical ventilation and intensive rehabilitation due to significant deconditioning. She was extubated on 10.11.2024 and gradually mobilized with the assistance of physical therapy. Hemodynamics remained stable on LVAD support, and there were no signs of pump thrombosis or significant complications related to the device. The patient was discharged home on 12.12.2024, 45 days after LVAD implantation, in stable condition on warfarin treatment. She was subsequently listed for heart transplantation.
The patient signed an informed consent to present this report.
This case demonstrates the efficacy of a triple-bridge mechanical circulatory support strategy in stabilizing a critically ill patient with cardiogenic shock. VA-ECMO provided rapid hemodynamic stabilization, enabling survival during the acute phase. Transition to the HeartMate 3 LVAD provided durable long-term support, while temporary RVAD addressed acute right ventricular failure, a common complication following LVAD implantation [1]. In our case report the patient had sequential RVAD implantation [2].
The patient’s outcome is consistent with similar cases reported in the literature. Ahmed et al. [3] described a triple-bridge strategy involving Impella (Abiomed Inc, Danvers, MA, USA), V-A ECMO, and HVAD (Medtronic, Minneapolis, MN, USA), while Schenk et al. [4] utilized VA-ECMO, biventricular assist device (BiVAD), and total artificial heart (TAH) as a bridge to transplantation. Moreover, recently Sharaf et al. [5] presented the sequential use of an intra-aortic balloon pump, Impella 5.5 (Abiomed Inc, Danvers, MA, USA), and VA-ECMO as a bridge to heart-liver-kidney transplantation.
The triple-bridge strategy was chosen, although the patient, after hemodynamic stabilization with VA-ECMO, was eligible for an urgent heart transplantation. The inability to urgently find a suitable graft highlights the challenges of mechanical circulatory support in countries with long heart transplantation waiting lists.
These studies highlight the importance of individualized, staged support strategies tailored to the patient’s clinical condition.
This case also underscores the challenges of managing multi-organ dysfunction and infections in patients undergoing MCS. Meticulous monitoring and multidisciplinary care are essential to address complications and optimize outcomes.
In conclusion, a triple-bridge strategy combining VA-ECMO, LVAD, and RVAD enabled successful stabilization and heart transplantation listing in this critically ill patient. This approach highlights the adaptability and effectiveness of modern MCS technologies in managing complex cardiogenic shock.
