Staged transition from veno-arterial extracorporeal membrane oxygenation to left ventricular assist device using Extra-VAD in acute myocardial infarction cardiogenic shock: a case report of individualized management

Introduction

Background

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) presents with severely impaired cardiac output and vital organ hypoperfusion and continues to carry high mortality despite conventional medical therapy. Mechanical circulatory support (MCS) has emerged as a critical intervention to stabilize hemodynamics, support vital organ perfusion, and serve as a bridge to recovery, a bridge to decision, or destination therapy. MCS requires a tiered clinical approach encompassing rapid decision-making in emergencies, comprehensive cardiac and multi-organ assessments during stable phases, meticulous weaning protocols, and well-timed transitions between support modalities (1). Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) provides immediate cardiopulmonary support during acute crises, whereas durable left ventricular assist device (LVAD) offers long-term circulatory replacement for eligible patients (2,3).

Given the complications associated with V-A ECMO, the limited assessment of right ventricular function, and the high mortality of direct bridging to a permanent LVAD, the interventional extracorporeal ventricular assist device can precisely deliver cardiac support and hemodynamic simulation comparable to a permanent LVAD, thereby gaining time for cardiac recovery and providing a basis for treatment decision-making (4,5). The MoyoAssist^® Extra-VAD (MagAssist, Suzhou, China), a percutaneously implantable, fully magnetically levitated extracorporeal ventricular assist device, provides up to 30 days of circulatory support. Operating at rotational speeds of 500–4,500 rpm and delivering flow rates of 0–10 L/min, it uses unfractionated heparin for anticoagulation, targeting an activated clotting time (ACT) of 160–200 s and an activated partial thromboplastin time (APTT) of 50–55 s. During Extra-VAD support, the patient can ambulate, and the precise cardiac assistance and hemodynamic status are consistent with an implanted LVAD, thereby providing a critical theoretical and practical basis for improving the success rate of bridging from V-A ECMO to LVAD.

Rationale and knowledge gap

Prolonged V-A ECMO support beyond 14 days is associated with significantly increased complication rates, which complicates subsequent treatment and clinical decision-making (6,7). In contrast, Extra-VAD delivers precise cardiac support, achieves hemodynamic effects comparable to those of implantable LVADs, and avoids the potential lung injury and systemic inflammatory response induced by membrane oxygenation. During this period, patients can eat independently and ambulate, thereby providing both theoretical rationale and practical clinical support for subsequent cardiac recovery and therapeutic strategy formulation.

Objective

We report the detailed diagnosis and treatment process, as well as the MCS strategy, for a critically ill patient with CS following AMI. Extra-VAD demonstrates feasibility as a bridging strategy from V-A ECMO to permanent LVAD implantation, while mitigating the risk of postoperative right heart failure. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0127/rc).

Case presentation

A 58-year-old male patient, measuring 1.75 m in height and weighing 90 kg (body mass index 29.3 kg/m²), with blood type O Rh-positive, had a medical history of hypertension, type 2 diabetes mellitus, and coronary artery disease, having previously undergone stent implantation in the left anterior descending (LAD). His long-term medications included enteric-coated aspirin (100 mg/day), clopidogrel (75 mg/day), and atorvastatin (20 mg/day). He presented to a regional hospital due to sudden onset of chest tightness. Emergency cardiac catheterization revealed 100% occlusion of the mid-segment stent in the LAD artery, 85% focal stenosis in the proximal first diagonal branch, diffuse 95% stenosis throughout the circumflex artery, and diffuse 75–95% stenosis from the proximal right coronary artery to the atrioventricular branch.

During the procedure, the patient developed severe respiratory distress and experienced cardiac arrest characterized by ventricular arrhythmias refractory to conventional cardiopulmonary resuscitation. After tracheal intubation, femoral V-A ECMO was initiated as rescue therapy. The patient then completed the percutaneous coronary intervention. A drug-coated balloon was used for angioplasty in the LAD, combined with intracoronary urokinase thrombolysis, resulting in Thrombolysis in Myocardial Infarction (TIMI) grade III flow. Due to a narrow pulse pressure and poor left ventricular function, an intra-aortic balloon pump (IABP) was implanted. Following resuscitation, the patient regained consciousness with progressive stabilization of multi-organ function and was extubated on day 3. After 14 days of ECMO and IABP assistance, cardiac ultrasound revealed a left ventricular end-diastolic diameter (LVEDD) of 68 mm, a right ventricle end-diastolic diameter (RVEDD) of 44 mm, a left ventricular ejection fraction (LVEF) of 25%, tricuspid annular plane systolic excursion (TAPSE) of 13 mm and a right ventricular fractional area change (RVFAC) of 28%. Due to worsening cardiovascular status and persistent electrical instability despite the utilization of V-A ECMO and IABP, the patient was transferred to our center for further management of his cardiac condition.

After arriving at our hospital, the patient’s blood pressure was recorded as 89/43 mmHg [norepinephrine 0.06 µg/kg/min corresponds to a vasoactive-inotropic score (VIS) of 6] while receiving MCS with V-A ECMO (speed 3,200 rpm, flow rate 3.83 L/min) and IABP. The treatment regimen was as follows: unfractionated heparin was administered as a continuous intravenous infusion to maintain an ACT of 160–180 seconds and an APTT of approximately 50 seconds. Antiplatelet therapy was withheld due to a low platelet count. Cardiac medications included oral metoprolol succinate (23.75 mg once daily) and spironolactone (20 mg once daily). Diuretic therapy consisted of intravenous furosemide (20 mg three times daily). Other heart failure medications were discontinued because of hypotension.

Laboratory findings showed several abnormalities, white blood cell count 15.98×10⁹/L (reference range 3–9 ×10⁹/L), troponin I (TNI) level 2,978 ng/L (reference range 0–26.2 ng/L), N-terminal pro-B-type natriuretic peptide (NT-proBNP) level 2,330 pg/mL (reference range 0–125 pg/mL), C-reactive protein (CRP) level 134 mg/L (reference range 0–4 mg/L), serum albumin level 29.8 g/L (reference range 35–50 g/L), and total bilirubin level 42.8 µmol/L (reference range 3–22 µmol/L), urea nitrogen 13.87 mmol/L (reference value 2.9–8.2 mmol/L), creatinine 118 µmol/L (reference value 44–133 µmol/L), platelet count 58×10⁹/L (reference range 150–300×10⁹/L), D-Dimer level 9.8 mg/L (reference range <0.5 mg/L), and antithrombin (AT) level 45% (reference range 80–120%). Arterial blood gas analysis indicated metabolic acidosis with a pH of 7.42 and a lactate level of 3.5 mmol/L (reference range 0–2 mmol/L). Urine output 60 mL/h. The electrocardiogram (ECG) showed sinus rhythm with frequent premature ventricular contractions (Figure 1). Chest X-ray revealed increased and blurred lung markings. Repeat cardiac ultrasound demonstrated LVEDD of 66 mm, RVEDD of 46 mm, LVEF of 22%, TAPSE of 12 mm, and RVFAC of 29%. The thrombocytopenia, coagulopathy, hypoalbuminemia, hyperbilirubinemia, elevated white blood cell count, and high CRP level were attributed to a combination of systemic inflammatory response, potential infection, heparin use during ECMO, and mechanical trauma. Treatments including platelet transfusion, fresh frozen plasma infusion, albumin infusion, and antibiotic therapy were administered.

Figure 1 The patient’s electrocardiogram on day 14 after onset showed frequent ventricular premature beats.

Despite aggressive management, norepinephrine at 0.08 µg/kg/min was required to maintain blood pressure, corresponding to a VIS of 8, urea nitrogen 23.9 mmol/L (reference value 2.9–8.2 mmol/L), creatinine 141 µmol/L (reference value 44–133 µmol/L), and urine output 50 mL/h. Because of abdominal pain and a markedly elevated white blood cell count, the intra-aortic balloon pump (IABP) was removed on day 18. The patient’s overall condition remained poor, and lactate levels repeatedly increased during attempts to reduce ECMO flow.

Given the risks associated with prolonged ECMO, the limited benefit of revascularization, and the challenge of finding a size-matched donor heart for his large body weight, implantation of an LVAD was considered the appropriate long-term therapeutic strategy. However, the presence of severe infection, metabolic acidosis, poor left ventricular function and multi-organ impairment rendered him unable to tolerate immediate LVAD implantation surgery. Furthermore, assessment of right ventricular and pulmonary function remained limited under V-A ECMO support, with evaluation indicating borderline right heart function (RVEDD of 46 mm, TAPSE of 12 mm, and RVFAC of 29%), suggesting a high risk of post-LVAD right heart failure and perioperative mortality rate.

A minimally invasive interventional Extra-VAD was implanted on day 19 (Figure 2). In accordance with the preoperative plan, a Medtronic LS96555-025 catheter (Medtronic, Minneapolis, MN, USA) was advanced into the left atrium via transseptal puncture through the right internal jugular vein to serve as the drainage cannula. We routinely create at least one complete loop of the cannula within the left atrium to reduce the risk of migration during ambulation. Key technical points for axillary artery cannulation: The right axillary artery was identified on the body surface. A 50 mm skin incision was made along the course of the artery. After blunt dissection of the subcutaneous tissue, the axillary artery was exposed. An 8 mm InterVascular graft (InterVascular S.A.S., La Ciotat, France) was then anastomosed to the artery in an end-to-side fashion. After starting Extra-VAD at 2,300 rpm and 3.52 L/min, ECMO flow was gradually reduced over minutes, guided by hemodynamic and echocardiographic assessments, leading to successful weaning from ECMO.

Figure 2 Overview of the Extra‑VAD system and implantation. (A) Schematic drawing of the device configuration. (B) Intraoperative photograph of the implanted Extra-VAD. (A,B) The red arrows indicate the arterial cannula and the blue arrows indicate the atrial drainage cannula. (C) Pre-implantation chest X-ray, obtained after removal of the IABP. (D) Post-implantation chest X-ray; the yellow arrow indicates the tip of the atrial cannula in the left atrium. IABP, intra-aortic balloon pump.

After 6 days of Extra-VAD support, the patient’s overall clinical condition showed improvement. Chest X-ray revealed clear lung fields, hemodynamic parameters remained stable, platelet count increased, and lactate levels returned to normal. Markers including CRP, TNI, and NT-proBNP approached normal ranges. Urine output was maintained at approximately 100 mL/h, and ventricular premature beats decreased compared to previous observations. No Extra-VAD-related complications were observed during the support period. However, cardiac function remained impaired, with LVEF of 23%. Consequently, on day 25, a Corheart^®6 LVAD (CoreMedical Technology Co., Ltd., Shenzhen, China) was implanted via median sternotomy, with a 12 mm artificial graft anastomosed to create a conduit from the left ventricular apex to the ascending aorta.

Postoperatively, the anticoagulation strategy employed was bridging therapy with heparin, followed by long-term treatment with warfarin [international normalized ratio (INR) 2–3] and aspirin (100 mg daily). The patient recovered well, with transient renal insufficiency that resolved promptly. He was discharged on postoperative day 38. All clinical events are presented in Figure 3. At the 1-year follow-up, the patient’s quality of life had significantly improved, with a 6-minute walk distance of 460 m. Echocardiography revealed an LVEF of 35%, TAPSE of 15 mm and RVFAC of 38%. The patient was scheduled for outpatient follow-up care with LVAD support, awaiting potential future therapeutic options.

Figure 3 A timeline figure illustrating the progression from AMI through various support modalities to final LVAD implantation and discharge. AMI, acute myocardial infarction; IABP, intra-aortic balloon pump; LVAD, left ventricular assist device; V-A ECMO, veno-arterial extracorporeal membrane oxygenation.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was provided by the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Key findings

The key finding of this case lies in that, for critically ill patients requiring transition from V-A ECMO to LVAD, the adoption of a minimally invasive Extra-VAD bridging strategy helps avoid membrane oxygenation-related inflammatory injury, achieves smooth hemodynamic transition, allows for more reliable assessment of right ventricular function, and facilitates the recovery of patient organ function and early mobilization, thereby optimizing the timing and conditions for the final LVAD implantation. This case provides the first systematic description of a successful bridging strategy using a percutaneously inserted, fully magnetically levitated Extra-VAD to bridge from V-A ECMO to a domestically produced durable LVAD in a region where Impella 5.0 is unavailable.

Strengths and limitations

In this patient, V-A ECMO was emergently initiated to stabilize respiratory and circulatory function, followed by a timely transition to an Extra-VAD that provided precise left ventricular assistance and avoided membrane oxygenator-related inflammatory injury, thereby creating a time window and optimal surgical conditions for the subsequent decision regarding durable LVAD implantation. The hemodynamic status provided by the Extra-VAD served as a pre-implantation trial run before durable LVAD placement, enabling accurate assessment of right ventricular and native pulmonary function, and substantially reducing the risks of post-implant right heart failure and respiratory failure. For acute right heart failure occurring after Extra-VAD implantation, our center has prior experience in establishing right ventricular assistance by using femoral vein puncture for drainage and a small incision at the left midclavicular line in the second intercostal space for pulmonary artery cannulation. Nevertheless, as a single-center, single-case report, the generalizability of these findings is limited. Long-term comparative data against direct transition or other bridging strategies are lacking. Future multicenter, prospective studies are warranted to further validate the universal applicability and long-term outcomes of this approach.

Comparison with similar research

Although traditional views considered LVAD implantation contraindicated in INTERMACS profile 1 chronic heart failure patients, recent improvements in short-term MCS outcomes have expanded its application in this population (8,9). Internationally, Impella 5.0 has been successfully used in multiple clinical cases as a bridging therapy from V-A ECMO to durable LVAD implantation (10,11). Due to limited availability of the Impella device in China, the domestically produced percutaneous Extra-VAD has emerged as a clinically valuable alternative, offering better accessibility, lower cost, and proven safety and efficacy for short- to medium-term heart failure support (12-14).

Explanations of findings

For emergency CS patients, this treatment strategy employs a three-phase approach: First, the goal is to overcome the resuscitation phase and optimize hemodynamic status using V-A ECMO. Second, an individualized MCS strategy is implemented to optimize end-organ function and reduce MCS-related complications (such as infection, hemolysis, and bleeding). Finally, the definitive treatment decision is made based on cardiac function recovery. Notably, during the Extra-VAD bridging phase, patients can be weaned from mechanical ventilation, resume oral intake, and engage in bedside rehabilitation activities. Concurrently, reduced anticoagulation intensity decreases ECMO-related complications and creates favorable conditions for both the selection of subsequent treatment strategies and enhanced recovery of organ function.

Implications and actions needed

Our institutional data indicate that early V-A ECMO decannulation with transition to Extra-VAD bridging represents a safe and effective treatment strategy for INTERMACS profile 1 patients with predominant left ventricular failure. Through Extra-VAD bridging, comprehensive assessment and optimization of right ventricular function can be achieved, along with evaluation of pulmonary function, thereby avoiding right ventricular failure and respiratory failure that might otherwise occur after direct transition from V-A ECMO to durable LVAD implantation. By delivering protocolized left ventricular unloading and right ventricular function optimization prior to LVAD implantation, this strategy significantly reduces ECMO-related complications and ameliorates pulmonary congestion. This staged approach, which requires an Extra-VAD bridge, depends on multidisciplinary team collaboration and is best implemented at high-volume cardiac centers with expertise in both percutaneous MCS and durable LVAD implantation. Nevertheless, large-scale studies with extended follow-up are needed to provide robust evidence-based support.

Conclusions

Based on the diagnosis and treatment experience of this critical case, we recognize that the MCS strategy for CS must embody the characteristics of rapid response, minimally invasive implementation, precise modulation, and flexible transition. A tailored MCS plan is the core determinant of successful patient rescue.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0127/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0127/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0127/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was provided by the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Kruse J, Ranade M. ECMO, VAD, Impella, and IABP: Primer on Mechanical Circulatory Support Devices. Tech Vasc Interv Radiol 2025;28:101042. [Crossref] [PubMed]
2. Acharya D, Manandhar-Shrestha N, Leacche M, et al. Extracorporeal membrane oxygenation as a bridge to advanced heart failure therapies. J Heart Lung Transplant 2023;42:1059-71. [Crossref] [PubMed]
3. Frye J, Tao M, Gupta S, et al. Safety and utility of mechanical circulatory support in patients with acute myocardial infarction complicated by cardiogenic shock: A systematic review and meta-analysis. Cardiovasc Revasc Med 2025;70:23-33. [Crossref] [PubMed]
4. Crespo-Diaz R, Hryniewicz K, Samara M, et al. Temporary mechanical circulatory support in left ventricular assist device candidates with right ventricular dysfunction: Acuity without long-term futility. J Heart Lung Transplant 2026;S1053-2498(26)01761-4.
5. Medina ML, Lewin D, Treede H, et al. Multicentre comparison of various microaxial pump devices as a bridge to durable assist device implantation. ESC Heart Fail 2025;12:2552-64. [Crossref] [PubMed]
6. Yun JH, Hong SB, Jung SH, et al. Epidemiology and Clinical Characteristics of Bloodstream Infection in Patients Under Extracorporeal Membranous Oxygenation. J Intensive Care Med 2021;36:1053-60. [Crossref] [PubMed]
7. Bunge JJH, Mariani S, Meuwese C, et al. Characteristics and Outcomes of Prolonged Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery: The Post-Cardiotomy Extracorporeal Life Support (PELS-1) Cohort Study. Crit Care Med 2024;52:e490-502. [Crossref] [PubMed]
8. Verma A, Chervu NL, Kim JJ, et al. Variation in mechanical circulatory support use for acute myocardial infarction cardiogenic shock. Heart 2026;112:563-8. [Crossref] [PubMed]
9. Ajello S, Pieri M, Dormio S, et al. Impella as Bridge to Durable Left Ventricular Assist Device in Acute Myocardial Infarction Cardiogenic Shock Patients. ASAIO J 2024;70:e150-2. [Crossref] [PubMed]
10. Bertoldi LF, Pappalardo F, Lubos E, et al. Bridging INTERMACS 1 patients from VA-ECMO to LVAD via Impella 5.0: De-escalate and ambulate. J Crit Care 2020;57:259-63. [Crossref] [PubMed]
11. Nguyen AH, Tehrani BN, Truesdell AG, et al. ECPELLA as a Bridge to Unexpected Myocardial Recovery in a Patient in Refractory Cardiogenic Shock. JACC Case Rep 2025;30:104040. [Crossref] [PubMed]
12. Li P, Wu L, Dong N. First experience of magnetically levitated extracorporeal left ventricular assist device for cardiogenic shock in China. ESC Heart Fail 2022;9:1471-3. [Crossref] [PubMed]
13. Tong L, Wu L, Dong N. Extracorporeal Left Ventricular Assist Device as a Bridge to Surgery for Ventricular Septal Rupture After Acute Myocardial Infarction. Patient Prefer Adherence 2023;17:2871-6. [Crossref] [PubMed]
14. Li P, Wu T, Hsu PL, et al. 30-day in vivo study of a fully maglev extracorporeal ventricular assist device. Artif Organs 2022;46:2171-8. [Crossref] [PubMed]