RESUMEN
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used to treat cardiogenic shock. However, a lack of left ventricle (LV) unloading and increased systemic afterload can cause pulmonary congestion. Impella (Abiomed, Danvers, MA, USA), a catheter-mounted micro-axial rotary pump, unloads the LV and provides hemodynamic support. However, Impella cannot support the right ventricle (RV), and RV dysfunction impedes weaning from VA-ECMO. A 50-year-old man with heart failure with reduced ejection fraction due to myocardial infarction developed moderate aortic stenosis and regurgitation, moderate mitral regurgitation, and tricuspid regurgitation. Aortic valve replacement, mitral valve replacement, and tricuspid valve replacement were performed. VA-ECMO with intra-aortic balloon pump (IABP) was initiated as he could not be weaned from cardiopulmonary bypass. The patient could not be weaned from IABP and VA-ECMO; therefore, Impella 5.0 was inserted instead of IABP on day 7. However, Impella 5.0 was ineffective due to RV dysfunction. Increased inhaled nitric oxide (iNO) dose lowered pulmonary vascular resistance, decreased RV afterload, and improved RV distension. He was weaned from VA-ECMO after increasing the flow from the Impella 5.0. Combining VA-ECMO with Impella and iNO improved hemodynamics in a patient with RV dysfunction, and Impella with iNO aided weaning from VA-ECMO. Learning objective: Combining venoarterial extracorporeal membrane oxygenation (VA-ECMO) with Impella (Abiomed, Danvers, MA, USA) and inhaled nitric oxide (iNO) can improve hemodynamics in a patient with right ventricular dysfunction, and iNO may aid weaning from VA-ECMO.
RESUMEN
Coronary button aneurysm is a well-known complication of aortic root surgery, especially in patients with Marfan syndrome. We present a case of a giant left coronary button aneurysm that occurred 20 years after an aortic root remodeling procedure was performed. A 32-year-old man with Marfan syndrome underwent the aortic root remodeling procedure for annuloaortic ectasia. Thirteen years later, an aortic aneurysm with chronic aortic dissection was diagnosed, and partial aortic arch replacement was performed. Twenty years after the first procedure, a 73-mm left coronary button aneurysm was observed. Due to dense adhesions from repeated surgeries, we approached the aneurysm through the artificial graft lumen, and the coronary artery was successfully reconstructed using Piehler's technique. When performing aortic root surgery for Marfan syndrome, the risk of coronary artery button aneurysm formation should be considered. Once an aneurysm is formed, a surgical strategy that assumes dense adhesions is essential.
