# Anterolateral papillary muscle suction causing low flow in a COVID-19 patient without medical history: a case report of central extracorporeal life support with left ventricular apex decompression

## TL;DR

A 38-year-old woman with severe heart failure from COVID-19 had low blood flow while on a life support machine, which was solved by repositioning a cannula after identifying suction from a heart muscle.

## Contribution

This case report highlights the use of transesophageal echocardiography to identify and resolve low flow in ECLS due to papillary muscle suction.

## Key findings

- Low pump flow in a patient on ECLS was caused by suction of the anterolateral papillary muscle into the cannula.
- Repositioning the cannula resolved the suction issue and allowed successful weaning from ECLS.
- Transesophageal echocardiography was critical in diagnosing the cause of low flow.

## Abstract

Left ventricular (LV) decompression is an essential strategy for improving early survival in patients with refractory cardiogenic shock. Low pump flow in patients on extracorporeal life support (ECLS) with LV apex decompression is a life-threatening issue. However, identifying the underlying causes of low flow can be challenging.

A 38-year-old woman with COVID-19-related fulminant myocarditis was treated with central ECLS with LV apex decompression. The pump flow in the intensive care unit (ICU) was intermittently low, and low flow alerts were frequent. The initial evaluation based on pressure monitor waveforms and transthoracic echocardiography failed to identify the underlying cause. Prompt bedside transesophageal echocardiography (TEE) revealed that the anterolateral papillary muscle was suctioned into the vent cannula of the LV apex during systole. The patient underwent a repeat sternal midline incision in the operating room, and the cannula at the LV apex was repositioned. There were no further suction events after the repositioning, and the patient was weaned from ECLS 12 days after admission to the ICU. The patient was discharged in a stable condition and without neurological deficits.

TEE is an important diagnostic tool to identify the underlying cause of low flow flow in patients undergoing ECLS with LV apex decompression.

The online version contains supplementary material available at 10.1186/s40981-024-00701-8.