Table 4.
Summary of the clinical case
 | The first figure shows extensive consolidation of the lung field secondary to coinfection with influenza and group A streptococcus. The patient was placed on bifemoral venovenous ECMO. The return cannula is placed just at the atrial caval junction. The access cannula for drawing in blood sits approximately 5 to 10 cm below the return cannula to prevent the recirculation of freshly oxygenated blood. |
 | The second figure shows extensive lung consolidation with evolving cardiogenic shock and biventricular failure. An additional 15 Fr arterial return pipe was placed in the right femoral artery. This improved arterial perfusion but increased the afterload and pressure on the failing left ventricle. |
 | The third figure illustrates the placement of a cardiac Impella* across the aortic valve. The patient's heart was so weak that it could no longer eject against the increased pressure generated by the ECMO arterial return. This is a potentially devastating complication as it leads to blood stasis and can result in thrombi in all 4 cardiac chambers and severe LV dilation and pulmonary edema. The Impella is, in essence, an Archimedes screw, which adds 2.5 L to the cardiac output and promotes forward flow, reducing the risk of stasis. |
 | The fourth figure shows the patient slowly improving. The placement of the Impella was complicated by both hemorrhage and hemolysis. Once the left ventricle had sufficiently recovered, it was removed. |
 | The fifth figure illustrates the progressive improvement in pneumonia and the patient's return from venoarterial venous to venovenous ECMO for just respiratory support. |
 | The patient was finally decannulated from ECMO on the ninth day of their ITU. They were liberated from mechanical ventilation on day 12 and fully recovered. |
| | The first figure shows extensive consolidation of the lung field secondary to coinfection with influenza and group A streptococcus. The patient was placed on bifemoral venovenous ECMO. The return cannula is placed just at the atrial caval junction. The access cannula for drawing in blood sits approximately 5 to 10 cm below the return cannula to prevent the recirculation of freshly oxygenated blood. |
| | The second figure shows extensive lung consolidation with evolving cardiogenic shock and biventricular failure. An additional 15 Fr arterial return pipe was placed in the right femoral artery. This improved arterial perfusion but increased the afterload and pressure on the failing left ventricle. |
| | The third figure illustrates the placement of a cardiac Impella* across the aortic valve. The patient's heart was so weak that it could no longer eject against the increased pressure generated by the ECMO arterial return. This is a potentially devastating complication as it leads to blood stasis and can result in thrombi in all 4 cardiac chambers and severe LV dilation and pulmonary edema. The Impella is, in essence, an Archimedes screw, which adds 2.5 L to the cardiac output and promotes forward flow, reducing the risk of stasis. |
| | The fourth figure shows the patient slowly improving. The placement of the Impella was complicated by both hemorrhage and hemolysis. Once the left ventricle had sufficiently recovered, it was removed. |
| | The fifth figure illustrates the progressive improvement in pneumonia and the patient's return from venoarterial venous to venovenous ECMO for just respiratory support. |
| | The patient was finally decannulated from ECMO on the ninth day of their ITU. They were liberated from mechanical ventilation on day 12 and fully recovered. |
*
The image of the Impella was taken and modified from flaticon. www.flaticon.com/free-icons/bolt” title = “bolt icons.” Bolt icons created by Freepik–Flaticon. ITU, Intensive Therapy Unit; LV, left ventricle.