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TÍTULO DEL CASO
“CENTRAL VENOARTERIAL ECMO IMPLANT AFTER MORE THAN 11 HOURS ON
CARDIOPULMONARY BYPASS DUE PRIMARY GRAFT FAILURE POST HEART
TRANSPLANTATION”. National Cardiovascular Institute. Incor-EsSALUD. Lima-Perú.
RESUMEN
31 years old male patient diagnosed with intractable ventricular tachyarrhythmia
secondary to Arrhythmogenic Right Ventricular Dysplasia (ARVD), who underwent heart
transplantation with cold ischemia time of 4 hours 10 minutes. Post aortic unclamping, severe
primary graft failure (PGF) was found, it impossible weaning off Cardiopulmonary Bypass
(CPB).
Central Venoarterial Extracorporeal Life Support (VA-ECMO) was implanted after 11
hours 15 min on CPB. 24 hours of onset of support, thrombus was found in the left atrium (LA)
with inadequate decompression of left cavities. Thrombectomy is performed in the LA and direct
insertion of a cannula into this cavity to get effective decompression of the LA/LV, joining it to
the cannula drainage of the right atrium; becoming a Central VA-ECMO + VENT-LA.
On day 8 the start of the support, significant recovery of ventricular function and adequate
tissue perfusion was found, performing the explant on day 9 and discharged home on day 28 post
implant.
IMPORTANCIA DEL CASO
There are no previous reports in the world about of explant success and survival to discharge
home of a patient after implantation of a Central VA-ECMO after more than 11 hours on CPB.
PRESENTACIÓN DEL CASO
We report the case of a male patient 31 years old, 75 kg, GS O +, with a history of
ARVD, implantable cardioverter defibrillator carrier; who entered our waiting list for heart
transplantation, diagnosed with recurrent ventricular tachyarrhythmia with hemodynamic impact
refractory to treatment, having been subjected to pharmacological antiarrhythmic therapy,
sympathetic denervation thoracoscopy (sympathectomy left T2-T5) and ablation with 3D
electroanatomic navigation system, unsuccessfully.
Patient was underwent to orthotopic heart transplantation with bicaval technique, having a
donor 17 years old, weight 65 kg, GS O positive, brain dead after cranial trauma, with
dobutamine (DBT) to 10 ug/kg/min, norepinephrine (NE) to 0.15 ug/kg/min and adequate cardiac
contractility by echocardiography. After a cold ischemia time of 4 hours 10 minutes, it is
observed by direct vision and transesophageal echocardiography, cardiac allograft contractile
inactivity categorizing as a severe PGF.
DIAGNÓSTICO DIFERENCIAL
1. Severe PGF.
2. Hyperacute rejection.
3. Right Ventricular Failure.
TRATAMIENTO
The internal environment, acid-base balance is optimized, inotropes and vasopressors
increased, intraaortic balloon pump (IABP) was placed without achieving wean off BPC.
After solving logistical problems, could connect the patient after 11 hours 15 min on PCB,
to a Central VA-ECMO with venous drainage cannula No. 36 in the right atrium, and arterial
cánula return No. 24 in the proximal portion of ascending aorta.
RESOLUCIÓN Y SEGUIMIENTO
At 24 hours after initiation of Central VA-ECMO support, despite adequate
anticoagulation, it is observed by transesophageal echocardiography in left atrial, thrombus with
inadequate decompression of left cavities. We decided to perform under support ECMO,
thrombectomy in the left atrium and placement of drainage cannula No. 17 in this cavity, which
was then joined by a system of tubing Y-shaped to the drainage cannula of the right atrium,
becoming a Central VA-ECMO + VENT-LA, optimizing the flow generated by the ECMO,
allowing adequate decompression of left cavities and reducing the risk of new formation of
thrombi.
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On day 8 of initiation of ECMO support, a significant recovery of ventricular function
(LVEF 40%) associated with adequate tissue perfusion is found, so weaning of ECMO support
begins with decreased blood flow 0.5 liters/min every 6 hours, optimizing anticoagulation,
inotropic support and mechanical ventilation. The support was explanted successfully on day 9.
He was extubated on day 14, transferred to the general care sector on day 19, and was discharged
home on day 28 post implant.
DISCUSIÓN
Ventricular arrhythmia refractory to treatment is a well recognized condition as an
indication for cardiac transplantation (1), as did our patient after suffering ARVD (Figure 1).
Among the possible complications in the perioperative period is described the PGF. It is related
to the dose of vasopressors donor, total ischemic time, marked differences in donor receiver
weight, etc. (2). Our patient had intermediate dose of vasopressor/inotropic: NA 0.15 ug/kg/min,
DBT 10 ug/kg/min and cold ischemia time of 4h 15 min (optimal <3 h) that may have contributed
to the origin of PGF.
Although there are case reports of heart transplant patients who received Central VAECMO implant due to failure of weaning from BCP (3,4), no one reported any case showing so
long support on BPC (> 11 h) prior to ECMO device implant like us.
It is also well known that the short duration circulatory support devices, such as VAECMO and CentriMag are indicated in patients with severe refractory to treatment PGF after
heart transplantation (2). We decided on the first being the only device we had at the time.
(Figure 2).
When there is no adequate decompression of left cavities with VA-ECMO there is a risk
of thrombus formation as happened with our patient (Figure 3), requiring thrombectomy under
ECMO support. There are several alternatives to solve the problem of inadequate decompression
of left cavities such as: use of inotropic, placing a Impella 2.5 device, using a pigtail intracavitary
catheter in the left ventricle or the placement of drainage cannula in the left atrium (VENT) (5).
The latter was performed in our patient, achieving adequate decompression of left cavities,
preventing the new formation of thrombi and improving the drainage flow; changing the name of
Central VA-ECMO to Central ECMO VA-ECMO + VENT-LA, where drainage both atria
cannulas were united in "Y- shaped". (Figure 4).
While it is true that most patients on VA-ECMO support due to PGF recover between on
day 3 and on day 7 of support, there is a group of patients who may take longer to recover (6) as
happened to him, probably because he was in a very critical situation.
PUNTOS DE APRENDIZAJE
-
-
While it is more likely that the longer support on CPB before implantation VA-ECMO
device, greater chance of complications; it does not rule out a possible successfull
weaning and survival to discharge home.
Perhaps it would be advisable from the start, placing drain cannulas in both atria and join
them with tubing "Y-shaped" in the case of implementation of Central VA-ECMO, for
better decompression of both cavities, generate better flow and reduce the risk of
thrombosis intracavitary.
It is possible to perform surgical procedures under ECMO support, such as left atrial
thrombectomy in our patient, with the respective care.
REFERENCIAS
1. Mehra, M. MD (Chair); Canter, C. MD; Hannan, M MD; et al. ISHLT GUIDELINE. The
2016 International Society for Heart Lung Transplantation listing criteria for heart
transplantation: A 10-year update. J Heart Lung Transplant 2016; 35:1-23.
2. Kobashigawa, J. MD; Zuckermann, A. MD; Macdonald, P. MD, PhD; et al. ISHLT
CONSENSUS Report from a consensus conference on primary graft dysfunction after
cardiac transplantation. J Heart Lung Transplant 2014; 33:327–40.
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3. Borges, E.; Ribeiro, C.; Salvatore, V.; et al. Experience of ECMO in Primary Graft
Dysfunction after Orthotopic Heart Transplantation. Arq Bras Cardiol 2015; 105(3):28591.
4. Lehmann, S; Uhlemann, M; Etz CD et al. Extracorporeal membrane oxygenation:
experience in acute graft failure after heart transplantation. Clin Transplant 2014, 28:
789–96.
5. Kotani, Y.; Chetan, D.; Rodrigues, W.; et al. Left Atrial Decompression During
Venoarterial Extracorporeal Membrane Oxygenation for Left Ventricular Failure in
Children: Current Strategy and Clinical Outcomes. Artificial Organs 2013, 37(1):29–36
6. Santise, G.; Panarello, G.; Ruperto, C.; et al. Extracorporeal membrane oxygenation for
graft failure after heart transplantation: a multidisciplinary approach to maximize weaning
rate. Int J Artif Organs 2014; 37(9):706-14.
IMÁGENES O FIGURAS
Figure 1. Typical Anatomical Piece of Arrhythmogenic Right Ventricular Dysplasia
(ARVD)
Figure 2. Patient with CENTRAL VA-ECMO support
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Figura 3. Transesophageal echocardiography showing thrombus in the left atrium with
inadequate decompression of left cavities.
Figure 4. Patient with CENTRAL VA-ECMO + LA-VENT support
Fecha: 30/09/2016
Author: Lescano-Alva, M1.
(1) Coordinator of Extracorporeal Life Support to ELSO. National Institute Cardiovascular.
Incor-EsSALUD. Lima-Perú.
Coauthors:
Prado-Gómez, T2.; Soplopuco-Palacios, F3.; Huancaviri-Sánchez, E4,; Tapia-Leonardo, J5.;
Morón-Castro, J6.
(2)
(3)
(4)
(5)
Co-coordinator of Extracorporeal Life Support to ELSO.
Co-director of Extracorporeal Life Support to ELSO.
Perfusionist Nurse.
Chief of the Perioperative Cardiology Service.
(6) Chief of the Cardiovascular Surgery Service.
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