PMC7545402_01
Histology (A) as well as immunohistological findings (B) in left ventricular endomyocardial biopsies illustrate a severe lymphocytic myocarditis with myocyte necrosis (blue circles) and infiltration of invading inflammatory cells (brown infiltrates).
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F1
A 49-years-old man of Asian background has been hospitalized at our institution for cardiogenic shock due to acute lymphocytic myocarditis, which was diagnosed by endomyocardial biopsy (Figure 1).
(A) IABP console during LV unloading with V-A-ECMO and iVAC2L. The diastolic pressure drop in the aortic pressure (green arrows) is attenuated as pressure increases in the gas chamber of iVAC2L (bottom waveform in blue). LV blood aspirated during systole is then ejected back in the ascending aorta. When the pressure falls in the gas chamber, ejection stops and aortic pressure quickly drops. The magnitude of the attenuation in the pressure drop may oscillate between successive beats due to transitory variations in myocardial conduction, mechanics and loading conditions generated by extra-systoles, arrhythmias or changes in intrathoracic pressure. (B) Aortography showing a watershed line around the left subclavian artery during 3.5 L/min V-A ECMO. (C) In the 5th heart beat following iVAC2L activation, the watershed line moved to the descending aorta demonstrating a decrease in afterload despite V-A ECMO support. Red circle: two-way valve (outlet) positioned next to the coronary ostia; red arrow: distal tip if the iVAC system in the left ventricle; green arrow: pigtail catheter.
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F2
After iVAC2L was inserted with the distal tip into the LV cavity, the paracorporeal membrane pump was filled with heparinized saline, and a wet-to-wet connection was established with the iVAC2L catheter (Supplementary Movie 1). A CS100 IABP console (Maquet Cardiovascular, Fairfield, NJ, USA) was used as a driver, and triggering was done using the aortic pressure (AP) waveform (Figure 2A). This was added to afterload reduction and increase in forward flow, which were evidenced by distal displacement of the watershed as contrast media became visible in the descending aorta (Figures 2B,C).