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Submission Template for Case Reports You must have signed informed consent from patients (or relatives/guardians) before submitting. Please anonymise the patient’s details as much as possible, eg, specific ages, occupations. TITLE OF CASE Right anterior thoracothomy for venous drainage – an unusual approach for ECMO initiation. SUMMARY Up to 150 words summarizing the case presentation and outcome End staged heart failure can develop into a life-threatening disorder that requires heart transplantation and/or mechanical cardiac support (MCS). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is indicated in reversible life-threatening circulatory failure or bridge to heart transplantation. Challenges in ECMO support include defining appropriate patient selection criteria and prognostic factors. We present a seven months old male patient, diagnosed dilated myocardiopathy with cardiogenic shock and needed of MCS. He was admitted in INTERMACS class 1 in our Institution and was bridged to a 10cc Berlin Heart Excor using a VA ECMO. Because the presentation of superior vena cava thrombosis, and small femoral vessel, a right anterior thoracotomy approach was preferred to access the right atrium for venous drainage. This unusual approach allowed us to implant a Berlin Heart Excor 9 days after the VA-EMCO initiation. No complication related to this cannulation approach was reported. BACKGROUND Why you think this case is important – why did you write it up? In specific situations, unusual approaches can be successfully used. In this case, the patient presented a right jugular vein thrombosis, which prevented cannulation of this vessel. The femoral vessels were small in this patient as usual. The right anterior thoracothomy proved to be a simple and safe approach to access the right atrium during the bedside approach and in an emergency situation. CASE PRESENTATION Presenting features, medical/social/family history Seven months old male patient, diagnosed dilated myocardiopathy and poor ventricular function, which was listed for cardiac transplantation. During hospital admission, he evaluated to a cardiogenic shock (INTERMACS 1) and need a MCS support. Because the presentation of right jugular thrombosis, a right anterior thoracotomy approach was the only viable option for venous drainage. After nine days the patient received a Berlin Heart Excor® and eleven months after a orthotopic heart transplantation was performed. INVESTIGATIONS If relevant DIFFERENTIAL DIAGNOSIS If relevant TREATMENT If relevant OUTCOME AND FOLLOW-UP Successful venous drainage and no complications was reported during the period of ECMO. DISCUSSION Include a very brief review of similar published cases There are any similar published cases in the literature. Almost all cases reviewed used central or peripheral canulation. LEARNING POINTS/TAKE HOME MESSAGES 3 to 5 bullet points – this is a required field Novels approaches ameliorates several of the current limitations to peripheral/central VA-ECMO therapy Potential for improving outcomes in VA-ECMO patients Page 1 of 2 Effective and relatively safe approach for ECMO REFERENCES -Boon Lim JK, Lee JH, Mok YH, Chan YH. Successful Use of Extracorporeal Membrane Oxygenation in a Neonate With Arterial pH Less Than 6.6. World J Pediatr Congenit Heart Surg. 2015 Jul;6(3):466-9. -Kyo M, Ohshimo S, Kida Y, Shimatani T, Torikoshi Y, Suzuki K et al. Pediatric cardiorespiratory failure successfully managed with venoarterialvenous extracorporeal membrane oxygenation: a case report. BMC Pulm Med. 2016 Aug 12;16(1):119. -Botha P, Deshpande SR, Wolf M, Heard M, Alsoufi B, Kogon B et al. Extracorporeal membrane oxygenator support in infants with systemic-pulmonary shunts. J Thorac Cardiovasc Surg. 2016 Sep;152(3):912-8. -Thiagarajan RR. Extracorporeal Membrane Oxygenation for Cardiac Indications in Children. Pediatr Crit Care Med. 2016 Aug;17(8 Suppl 1):S155-9. FIGURE/VIDEO CAPTIONS figures should NOT be embedded in this document Date: 08/30/2016 Author: Guilherme Viotto Rodrigues da Silva, Luiz Fernando Caneo, Maria Aparecida Batistão Gonçalves, Vanessa Alves Guimaraes, Filomena Regina Barbosa Gomes Galas, Marcelo Biscegli Jatene Page 2 of 2