Arrhythmia-induced cardiomyopathy: A potentially reversible cause of refractory cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation.

Abstract Background The most severe form of arrhythmia-induced cardiomyopathy in adults— refractory cardiogenic shock requiring mechanical circulatory support—has rarely been reported. Objective To describe the management of critically ill patients admitted for acute, nonischemic or worsening of previously known cardiac dysfunction and recent-onset supraventricular arrhythmia who developed refractory cardiogenic shock requiring venoarterial-ECMO (VA-ECMO). Methods This study is a retrospective analysis of prospectively collected data. Results Between 2004 and 2018, 35 patients received VA-ECMO for acute, nonischemic cardiogenic shock and recent supraventricular arrhythmia (77% atrial fibrillation). Cardiogenic shock was the first disease manifestation in 21 (60%) patients. Characteristics at ECMO implantation (median [IQR]) were: SOFA score: 10 [7–13], inotrope score: 29 [11–80], left ventricular ejection (LVEF) fraction: 10% [10–15] and lactate level: 8 [4–11] mmol/l. For 12 patients, amiodarone and/or electric cardioversion successfully reduced arrhythmia, improved LVEF and enabled weaning-off VA-ECMO; 11 had long-term survival without transplantation or long-term assist device. Eight patients experiencing arrhythmia-reduction failure underwent ablation procedures (7 atrioventricular node with pacing and 1 atrial tachycardia) were weaned-off VA-ECMO; 7 survived. Among the remaining 15 patients without arrhythmia reduction or ablation, only the 6 bridged to heart transplantation or left ventricular assist device survived. Conclusion Arrhythmia-induced cardiomyopathy, mainly atrial fibrillation-related, is an underrecognized cause of refractory cardiogenic shock, and should be considered in patients with nonischemic cardiogenic shock and recent-onset supraventricular arrhythmia. VA-ECMO support allowed safe arrhythmia reduction or rate control by atrioventricular-node ablation while awaiting recovery, even among those with severe left ventricular dilation.