Veno-arterial ECMO in severe acute right ventricular failure with pulmonary obstructive hemodynamic pattern.

Extracorporeal membrane oxygenation (ECMO) is an effective rescue method for severe respiratory and cardiac failure. Right ventricular (RV) failure with cardiogenic shock is a critical condition with generally poor prognosis unless aggressive therapeutical measures are undertaken. Authors report on their initial experience with ECMO support in severe RV failure with cardiogenic shock caused by an obstructive hemodynamic pattern. Four patients with cardiogenic shock due to severe RV failure related to pulmonary arterial hypertension (2 patients), congenital heart disease with Eisenmenger physiology (1 subject) and massive pulmonary embolism (1 patient) were supported with emergency veno-arterial ECMO. ECMO circuit was instituted using peripheral cannulation in all subjects. Immediate hemodynamic and ventilatory improvement was observed in all patients. The mean support duration was 11 days (range 5-16 days), 2 (50%) patients were successfully weaned off ECMO and survived to hospital discharge. The other 2 patients were considered by mutual consensus to have irreversible organ damage, the ECMO support was withdrawn and the patients died. Bleeding complications were the main complications observed. As per initial experience, veno-arterial ECMO allows bypassing of the pulmonary bed, therefore, relieves the RV pressure overload and does not cause further elevation of the pulmonary pressures in contrary to RV assist devices. This aggressive management approach requires further clinical evaluation in order to establish its definite role in critical RV failure.

Cardiogenic shock in patient with posterior postinfarction septal rupture--successful treatment with extracorporeal membrane oxygenation (ECMO) as a ventricular assist device.

We present the case of a 62-year-old female patient admitted to our center for cardiogenic shock due to large inferior myocardial infarct. Echocardiography revealed dysfunction of left ventricle, dilation of right ventricle, mitral valve insufficiency, and a large posterior ventricular septal defect (VSD). Coronary angiography showed occlusion of the right coronary artery. An attempt of percutaneous coronary intervention (PCI) of right coronary and posterior descending artery was not successful due to old thrombi. Despite inotropes and intraaortic balloon pump (IABP) there was severe hemodynamic instability. Therefore, we commenced veno-arterial extracorporeal membrane oxygenation (ECMO) as a ventricular assist device (VAD). Immediately we obtained the stabilization of the patient and the improvement of the clinical conditions. The third day after implantation, the closure of the defect, mitral valve plasty, and bypass to posterior descending artery were performed. The patient was discharged from the hospital 59 days after the operation. Six months after the operation, the patient was in good condition.

Hepatic tear as an elusive cause of hemoperitoneum complicating cardiac surgery.

We report an unusual source of intra-operative bleeding in a patient undergoing cardiosurgical reoperation. After sternotomy, hematocrit dropped significantly. Only intra-thoracic bleeding from adhesions was considered to be responsible for the anemia. During reperfusion, abdominal wall was distended with a bluish bulge in the right hemidiaphragm. Immediate laparotomy revealed bleeding from a tear in the right hepatic lobe without any diaphragm injury. The tear was likely caused by blunt trauma from an oscillating saw. We emphasize cautious use of an oscillating saw in patients with hepatic congestion undergoing a repeat sternotomy. We propose that lifting the sternum in redo procedures might prevent the hepatic tear.