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TÍTULO DEL CASO
“Use of CentriMag as biventricular assist device with extracorporeal membrane
oxygenator as bridge to recovery, in a patient with refractory cardiogenic shock by humoral
rejection following heart transplantation”. National Institute Cardiovascular. IncorEsSALUD. Lima-Perú.
RESUMEN
We report a case of bi-VAD with extracorporeal membrane oxygenation in the RVAD circuit. A
37-years old woman, eight months after cardiac transplantation, who was admitted to hospital with
clinical symptoms of acute heart failure secondary to acute humoral rejection with cardiogenic
shock and severe hypoxemia. CentriMag was used as bi-VAD, adding an extracorporeal
membrane oxygenator in the RVAD circuit. Also received treatment for humoral rejection with
corticosteroid therapy pulses, thymoglobuline, rituximab and plasmapheresis. She required reentry
OR twice by bleeding. At 36 hours, inotropic and vasopressor support were withdrawn;
approximately at 46 hours tissue perfusion was normal.
After seven days, respiratory function improved and extracorporeal membrane oxygenator was
successfully retired. She had upper gastrointestinal bleeding (day 12), which was controlled. After
16 days of bi-VAD, and appropriate weaning tests, successful removal was performed in the OR,
requiring support with dobutamine and nitroprusside. Tracheostomy was performed and ventilatory
support was weaned after 38 days and she was discharged from ICU after 48 days. She was
discharged from hospital without tracheostomy after 99 days.
IMPORTANCIA DEL CASO
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In our country, be the pioneer and unique case of biventricular assist device implantation with
the CentriMag system, and also had a successful simultaneous biventricular explant.
Because also an extracorporeal membrane oxygenator was used in the RVAD circuit, the early
days post implant of the bi-VAD, until respiratory function improved, thereby proceeded to
remove the oxygenator and left the patient alone with biventricular support.
PRESENTACIÓN DEL CASO
We report a 37-year old woman with a history of ischemic dilated cardiomyopathy with advanced
heart failure; who underwent surgery orthotopic cardiac transplantation by bicaval technique in
June 2015.
In November 2015, she presented an episode of symptomatic 3R cellular rejection without
hemodynamic compromise requiring hospitalization, corticosteroids therapy pulse and
readjustment of immunosuppressive treatment, with good response to treatment was discharged a
week later.
She was again admitted to hospital on 02/10/2016 with clinical symptoms of acute heart failure
secondary to acute humoral rejection with hemodynamic compromise, requiring inotropic and
vasopressor support increasing doses in the next 48 hours, associated with compromised tissue
perfusion (anuria, high lactate, decreased mixed venous saturation, etc.).
Transthoracic echocardiography was performed showing severe bi-ventricular dysfunction (LVEF:
30%, RVFS: 19%, velocity S' free wall basal segment of RV: 5, TAPSE: 6). Vasopressor
requirement was high: dobutamine 10 ug/Kg/min, Norepinephrine 0.6 ug/kg/min, IABP 1:1.
Despite optimal management, hemodynamic instability and requirements of oxygen and
ventilatory support were high; showing lactate 7 mmol/L, anury, CVP 32, PCWP 26, mixed venous
saturation: 43%, CI <2.0 L/min/m2, mechanical ventilation mode AC-volume with FiO2 70%.
Given this situation we decided to implant CentriMag bi-ventricular assist device with an
extracorporeal membrane oxygenator (EOS ECMO Oxygenating Module, Phisio Coated, Sorin
Group) in the RVAD circuit, as a bridge to recovery or cardiac retransplantation, performing the
surgical implant bi-VAD by sternotomy in operating room on February 13, 2016 (Figure 1). The
patient required readmission to the OR twice by surgical bleeding, which was controlled.
At 36 hours, the inotropic and vasopressor support was completely withdrew off, receiving support
with CentriMag bi-VAD to blood flows of 4.5 L/min in the RVAD and 4.8 L/min in the LVAD.
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At 46 hours, the complete normalization of tissue perfusion (lactate < 2 mmol/L, urine flow > 1
mL/kg/hour, central venous saturation > 70%, etc.) was achieved.
TRATAMIENTO
The etiology of cardiogenic shock was humoral rejection for which received following treatment:
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corticosteroids therapy pulse,
thymoglublin 1.5 mg/kg/day for 7 days
rituximab 500 mg/doses, once weekly by two doses
plasmapheresis with 3 sessions by week by 2 weeks
RESOLUCIÓN Y SEGUIMIENTO
After significant improvement in respiratory function, oxygenator was removed seven days after
bi-VAD implantation, bi-VAD support was remained with CentriMag (Figure 2).
Over the next days, biventricular function was improving gradually, therefore after 10 days of biVAD implantation, biventricular support weaning began with vasodilator and inotropic support,
which was not successful because the patient developed severe right ventricular dysfunction.
On day 12 of the support, the patient had upper gastrointestinal bleeding, with a fall in hemoglobin
of 9 g/dL to 6 g/dL, requiring transfusion therapy and performing upper gastrointestinal endoscopy,
confirming the diagnosis of stress ulcer, which was treated properly.
After 15 days of bi-VAD support; with biventricular function already recovered and inactive
gastrointestinal bleeding, weaning biventricular support was again started with progressive
decrease of blood flow in both circuits, 0.5 L/min every 6 hours; with clinical, echocardiographic
and hemodynamic monitoring. Inotropic support with dobutamine was started at 3 ug/kg/min, plus
intravenous selective pulmonary vasodilators (intravenous nitroprusside, inhaled iloprost therapy);
mechanical ventilation support was optimized as well as anticoagulation.
On day 16 of bi-VAD support (February 29, 2016), we were able to explant successful bi-VAD
support in the operating room, providing support cardiovascular only with dobutamine and
intravenous nitroprusside.
After the successful withdrawal of bi-VAD (CentriMag), as part of weaning from mechanical
ventilation, the patient underwent tracheostomy, the same day that bi-VAD was removed. The
patient received intensive chest physiotherapy and ventilatory support was removed successfully
on March 20, 2016. She was discharged from the intensive care unit on March 30, 2016. She was
discharged to home, and without tracheostomy tube, on May 19, 2016.
DISCUSIÓN
The addition of an oxygenator into a temporary support RVAD already has been reported.
Leidenfrost J et. al. reported 267 continuous-flow left ventricular assist device, continuous-flow
RVAD insertion for cardiogenic shock was utilized in 27 (10%) patients due to the inability to
wean off cardiopulmonary bypass or due to refractory RV failure postoperatively. Of these patients,
12 (46%) were added an oxygenator in the RVAD circuit, in order to help maximize resuscitation.
They reported decrease in 30-day mortality with the use of an oxygenator in the RVAD circuit
versus only RVAD, in patients with acute right ventricular failure after continuous-flow left
ventricular device (1).
Vakhtang Tchantchaleishvili et. al. reported a case of a patient 8 days after heart transplantation,
developed diffuse alveolar hemorrhage. In anticipation of the imminent increase in pulmonary
vascular resistance, and in an attempt to prevent right ventricular failure, a right ventricular assist
device with oxygenator was implanted. They initially withdrew off the oxygenator, followed by a
scheduled weaning from RVAD using transesophageal echocardiography, subsequently the patient
was successfully removed from RVAD (2).
Zaccagni J. et. al. reported a patient underwent a cardiac catheterization revealing severe
biventricular dysfunction, required veno-arterial ECMO, after one week, her biventricular failure
had not improved, she was implanted a Berlin Heart EXCOR biventricular assist device and she
was listed for cardiac transplantation. After three weeks, she had pulmonary hemorrhage and
pulmonary hypertension caused RVAD outflow obstruction and cardiovascular collapse secondary
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to acute decrease in the left atrial venous return. She received conventional treatment with poor
response. Then, a pediatric Quadrox-iD oxygenator was interposed into RVAD circuit. She
remained on oxygenator for 15 days (3).
Betit P. et. al. reported a patient who initially received extracorporeal ECMO support, considering
that the cardiac support would be extended, the patient was implanted a bi-VAD. In their
postoperative course developed acute respiratory distress syndrome, who did not adequately
respond to conventional therapy (recruitment maneuvers, high-frequency oscillatory ventilation).
A Quadrox-iD membrane oxygenator was placed in series with right-sided VAD. The outcome had
not successfully (4).
García-Guereta L. et. al. reported a patient with severe heart failure and respiratory failure
secondary to a probable myocarditis, who was successfully bridged to heart transplantation,
initially with ECMO and after 9 days with an EXCOR biventricular assist device and oxygenator
membrane added in the outflow cannula of the left pump. The membrane oxygenator was
disconnected after three days of bi-VAD implantation. The patient underwent a successful
transplantation after 210 days biventricular support (5).
We reported a patient who was implanted bi-VAD with an oxygenator in the RVAD circuit,
because this patient had severe biventricular failure and severe respiratory function compromise.
This patient had a successfully outcome.
PUNTOS DE APRENDIZAJE
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Initial experience in the indication, management and care of patients with bi-VAD with a
membrane oxygenator in the RVAD circuit.
It is possible to add extracorporeal membrane oxygenator into the circuit of right ventricular
assist device, in the case of patients with right biventricular dysfunction and respiratory
compromise, and removed once the respiratory function has improved.
Independently of mechanical circulatory support, we must emphasize giving proper treatment
to the etiology of cardiogenic shock that caused the need for mechanical circulatory support
Consider selective pulmonary vasodilator therapy during weaning from ventricular assist to
reduce the risk of failure of the right ventricle.
REFERENCIAS
1. Leidenfrost J, Prasad S, Itoh A, Lawrance CP, Bell JM, Silvestry SC. Right ventricular assist
device with membrane oxygenator support for right ventricular failure following implantable
left ventricular assist device placement. Eur J Cardio-Thorac Surg Off J Eur Assoc CardioThorac Surg. 2016 Jan;49(1):73–7.
2. Tchantchaleishvili V, Staicu SA, Giampoli EJ, Chen L, Massey HT. Utilizing right ventricular
assist device with extracorporeal membrane oxygenator for management of diffuse alveolar
damage after orthotopic heart transplant. Artif Organs. 2015 Mar;39(3):289–91.
3. Zaccagni HJ, Timpa JG, O’Meara LC, Alten JA. Long-term membrane oxygenator use to
support an infant with acute respiratory distress syndrome on biventricular assist device.
Interact Cardiovasc Thorac Surg. 2013 Jul;17(1):196–8.
4. Betit P, Matte GS, Howe R, Iudiciani P, Barrett C, Thiagarajan R, et al. The addition of a
membrane oxygenator to a ventricular assist device in a patient with acute respiratory distress
syndrome. J Extra Corpor Technol. 2011 Dec;43(4):264–6.
5. Garcia-Guereta L, Cabo J, de la Oliva P, Villar MA, Bronte LD, Goldman L, et al. Ventricular
assist device application with the intermediate use of a membrane oxygenator as a bridge to
pediatric heart transplantation. J Heart Lung Transplant Off Publ Int Soc Heart Transplant.
2009 Jul;28(7):740–2.
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IMÁGENES O FIGURAS
Figure 1. CentriMag bi-ventricular assist device with an extracorporeal membrane
oxygenator in the RVAD circuit.
Figure 2.
Oxygenator was removed seven days after bi-VAD implantation, bi-VAD support was
remained with CentriMag
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Abbreviations:
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IABP: Intra-aortic balloon pump
RVFS: right ventricle fractional shortening
Bi-VAD: bi-ventricular assist device
RVAD: right ventricular assist device
LVAD: left ventricular assist device
OR: operating room
LVEF: left ventricular ejection fraction
TAPSE: tricuspid annular plane systolic excursion
RV: right ventricle
CVP: central venous pressure
PCWP: Pulmonary capillary wedge pressure
CI: Cardiac Index
ICU: Intensive care unit
Fecha: September 27, 2016
Author: Lescano-Alva, M1.
(1) Coordinator of Extracorporeal Life Support to ELSO. National Institute Cardiovascular.
Incor-EsSALUD. Lima-Perú.
Coauthors:
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Prado-Gómez, T2.; Soplopuco-Palacios, F3.; Palma-Urtecho, L4.; Soplopuco-Palacios, C5.;
Reyes-Torres, A6.
(2) Co-coordinator of Extracorporeal Life Support to ELSO.
(3) Co-director of Extracorporeal Life Support to ELSO.
(4) Heart Surgeon.
(5) Cardiologist Cardiovascular Critical Care.
(6) Chief of the Department of Cardiovascular Surgery.
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