Extracorporeal Membrane Oxygenation (ECMO) for Pulmonary and/or Cardiopulmonary Support-a Brief Review and Our Experience.

Extracorporeal membrane oxygenation (ECMO) is a modality utilized for partially or completely supporting the cardiac and/or pulmonary function. There are multiple vascular access techniques depending upon the necessity and the mode of ECMO used. ECMO has evolved over the years as an integral part of the cardiac care discipline. Historically, this lifesaving modality began as an extension of cardiopulmonary bypass and was associated with adverse outcomes. Currently, ECMO has evolved as an accepted and viable solution to patients with severe cardiac/respiratory/cardiorespiratory failure that is refractory to conservative management. The outcomes of patients on ECMO are dependent on multiple factors originating from demographic and pathophysiological status of patients as well as the control of homeostasis during ECMO within the acceptable range. Various studies have been published by many practitioners over past decades since the dawn of ECMO era. A brief review of such experience is summated, and a conclusion is derived about the clinical course of the patients on ECMO, while adding the author's experience about the same in a tertiary care large-volume center.

Management of intrapulmonary hemorrhage in patients undergoing pulmonary thrombo-endarterectomy.

Massive pulmonary hemorrhage during pulmonary thromboendarterectomy (PTE) can be managed by a conservative approach with mechanical ventilatory support, positive end-expiratory pressure, lung isolation, reversal of heparin, and correct of coagulopathy. We present three challenging cases that developed intrapulmonary hemorrhage during/after PTE and managed successfully. The first patient had bleeding from the bronchial artery and right internal mammary collaterals, which was managed by coil-embolization. The second patient had a breach in the blood airway barrier in the right upper lobar segment of the lung, and the repair was done using a surgical absorbable hemostat. The third patient developed reperfusion injury, he was instituted on veno-venous extracorporeal membranous oxygenation, a week later, the patient recovered completely. An algorithm was adopted and modified to our requirements; all the 3 challenging intrapulmonary hemorrhage cases were successfully managed. This algorithm can be used for satisfactory outcomes in patients who suffer intrapulmonary hemorrhage during PTE.

Veno-arterial extracorporeal membrane oxygenation: Special reference for use in 'post-cardiotomy cardiogenic shock' - A review with an Indian perspective.

The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve 'milieu intérieur'. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.

Right-sided aortic arch with Kommerell's aneurysm.

We present a case report of a 55-year-old lady who presented with progressive dysphagia and was diagnosed with a Kommerell's aneurysm and a right-sided aortic arch. This case report outlines our management strategy and the challenges encountered during the perioperative period in a patient with this rare anomaly.

Management issues during HeartWare left ventricular assist device implantation and the role of transesophageal echocardiography.

Left ventricular assist devices (LVAD) are increasingly used for mechanical circulatory support of patients with severe heart failure, primarily as a bridge to heart transplantation. Transesophageal echocardiography (TEE) plays a major role in the clinical decision making during insertion of the devices and in the post-operative management of these patients. The detection of structural and device-related mechanical abnormalities is critical for optimal functioning of assist device. In this review article, we describe the usefulness of TEE for optimal perioperative management of patients presenting for HeartWare LVAD insertion.

Management of a patient with hyperkalemic periodic paralysis requiring coronary artery bypass grafts.

Hyperkalemic periodic paralysis (HPP) is an autosomal-dominant inherited muscle disease characterized by episodes of flaccid weakness and intermittent myotonia. There are no previous reports in the literature about anesthesia for cardiac surgery with cardiopulmonary bypass in this disorder. We describe perioperative anesthetic management for on-pump coronary artery bypass grafting in a 75-year-old man with a history of hyperkalemic periodic paralysis. This case report outlines our management strategy and the issues encountered during the perioperative period.