Aortic Thrombus Formation During Venoarterial Extracorporeal Membrane Oxygenation for Ventricular Septal Rupture
Notice bibliographique
Résumé
A 59-year-old male with a late-presentation inferior ST-elevation myocardial infarction presented with cardiogenic shock and multiorgan failure due to a large ventricular septal rupture (VSR; 2.6 cm) with left-to-right shunting (Video 1, view video online) despite an intra-aortic balloon pump (IABP). We performed femoral cannulation of venoarterial extracorporeal membrane oxygenation (VA ECMO) as a bridge-to-surgery. We suspected the absence of left ventricular (LV) ejection through the aortic valve, based on a lack of arterial pulsatility with the IABP on standby, posing a risk of aortic root thrombosis. We performed transesophageal echocardiography to exclude an aortic thrombus and optimize hemodynamics to ensure there was both LV ejection and systemic perfusion. With VA ECMO flows of 3.75 LPM, the aortic valve remained closed and there was spontaneous echo contrast and early thrombus formation in the aortic root (Video 2, view video online). We reduced VA ECMO flows to 3.25 LPM and maintained IABP support at 1:1 to reduce afterload to the heart, which resulted in LV ejection through the aortic valve and an improvement of spontaneous echo contrast (Video 3, view video online). The spontaneous echo contrast cleared completely with a further reduction in VA ECMO flows to 3.00 LPM (Video 4, view video online). The patient was ultimately deemed ineligible for VSR patch repair and died shortly after the implementation of a palliative approach to care. A cornerstone of management for VSR is afterload reduction using an IABP and vasodilators to promote forward flow as a bridge to surgical repair. VA ECMO has been used in severe cases to reduce surgical risk by reversing multiorgan failure and allowing for infarct evolution.1Ariza-Solé A. Sánchez-Salado J.C. Sbraga F. et al.The role of perioperative cardiorespiratory support in post infarction ventricular septal rupture-related cardiogenic shock.Eur Heart J Acute Cardiovasc Care. 2020; 9: 128-137Crossref PubMed Google Scholar, 2Muller Moran H.R. Dutta V. Yan W. et al.Extracorporeal membrane oxygenation before surgical repair of a postinfarction ventricular septal defect.J Thorac Cardiovasc Surg. 2018; 155: e121-e123Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 3Neragi-Miandoab S. Michler R.E. Goldstein D. D’Alessandro D. Extracorporeal membrane oxygenation as a temporizing approach in a patient with shock, myocardial infarct, and a large ventricle septal defect; successful repair after six days.J Card Surg. 2013; 28: 193-195Crossref PubMed Scopus (21) Google Scholar However, the use of femoral VA ECMO increases LV afterload4Burkhoff D. Sayer G. Doshi D. Uriel N. Hemodynamics of mechanical circulatory support.J Am Coll Cardiol. 2015; 66: 2663-2674Crossref PubMed Scopus (222) Google Scholar and will worsen left-to-right shunting through a VSR. These unique and unfavourable hemodynamics create a challenge to provide systemic perfusion with VA ECMO while allowing for LV ejection through the aortic valve in the presence of a VSR. LV ejection can be monitored using the pulse pressure as a surrogate or by echocardiographic visualization of aortic valve opening. Some methods of LV unloading promote LV ejection, but we lack randomized data comparing devices and strategies.5Russo J.J. Aleksova N. Pitcher I. et al.Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock.J Am Coll Cardiol. 2019; 73: 654-662Crossref PubMed Scopus (117) Google Scholar We illustrate the real-time development of aortic root thrombus, a devastating complication of VA ECMO, in response to an increased afterload produced by ECMO support in the presence of a VSR.Novel Teaching Points•VA ECMO can provide cardiac support as a bridge to surgical repair of ventricular septal rupture, but it will increase left-to-right shunting.•Aortic thrombus is a complication of VA ECMO that results when there is insufficient forward flow through the aortic valve.•Aortic thrombus may occur with VA ECMO for VSR despite LV unloading, and it is more likely to occur with higher VA ECMO flows. •VA ECMO can provide cardiac support as a bridge to surgical repair of ventricular septal rupture, but it will increase left-to-right shunting.•Aortic thrombus is a complication of VA ECMO that results when there is insufficient forward flow through the aortic valve.•Aortic thrombus may occur with VA ECMO for VSR despite LV unloading, and it is more likely to occur with higher VA ECMO flows. Dr Kiamanesh receives funding from the Arthur J.E. Child Cardiology Fellowship. The other authors have no funding sources to declare.
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|---|---|---|
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| Méta-épidémiologie (sens large) | 0,000 | 0,000 |
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| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
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