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TITLE OF THE CASE
“ECMO support experience for the management of right ventricular failure at Clinica
CardioVID in Medellin (Colombia)”
SUMMARY Up to 150 words summary of presentation and resolution of the case
After reviewing the international literature it was found that ECMO could be a good alternative as
a rescue therapy in patients with acute right ventricular failure in the immediate postoperative of
heart transplant and other high complexity cardiac surgeries (1)(2). A detailed analysis on our
experience was performed from 2013 to date finding 7 (1.4%) patients who met the criteria for
post cardiectomy right heart failure and whom have been supported with ECMO with a survival
rate of 85.7% (6 patients) at six months.
IMPORTANT THE CASE Why is the case important? Why do you want to present it?
ECMO is a type of circulatory assistance device recently introduced in our country. Clinica
CardioVid has been pioneer in the support for both the pediatric and adult population attaining
good results and meeting with the high complexity needs of the postoperative patient with a
casuistic of 50 patients. With our experience it can be shown that this therapy is a good
management alternative in the scenario of a difficult to manage disease, as the acute right
ventricular failure is, and with high postoperative mortality rates as high as 60-70% (3).
CASE PRESENTATION Patient presentation, medical records/social/family history
7 out of 50 patients presenting with acute right heart ventricular failure in the immediate cardiac
surgery postoperative are presented. 5 men (71.4%) and 2 women (28.5%), mean age 53 years
(32-72 years), in the immediate postoperative of: mitral bioprosthesis plus failed plasty, right
ventricle aneurism correction plus tricuspid and pulmonary bioprosthesis, sinotubular junction
plus supracoronary tube graft, mitral bioprosthesis due to previous dysfunction, mitral plasty plus
neochords and two heart transplants. The mean aortic clamp time was 157 minutes (1). All of the
patients met the following criteria for the diagnosis of acute right heart ventricular failure:
echocardiographic hypocontractility of the right ventricle, increased mean PAP >50 mmHg,
decreased MAP <40 mmHg, increased CVP >10 mmHg. Pharmacological support included:
dobutamine, levosimendan, milrinone, norepinephrine, adrenaline, vasopressin, reaching a VIS
(Vasoactive- Inotropic Score) over 15 (4) in all the cases.
INVESTIGATIONS In case of being relevant
There is little evidence in the literature regarding this rescue treatment.
TREATMENT In case of being relevant
 In all the patients Medtronic 550 Bio-Console was used. With DIDECO membrane
oxygenators and Affinity AP40 (Medtronic) centrifugal blood pump, venous saturation
sensor and online hematocrit, temperature sensor and Stocker heat exchangeable.
 For all the cases arterio-venous femoral cannulation was performed using MedtronicBiomedicus cannula and distal perfusion catheter with heparin infusion at 6cc/hr to
maintain the permeability, previous administration of 5000 units of heparin.
 Systemic anticoagulation was started on an average of 72 hours.
 The average use of blood homologous components was 3 u/day.
 The average of the serum lactate at the beginning of the ECMO support was 6.29 mmol/L
and at 12 hours of therapy was 2.86 mmol/L.
 The average of stay on circulatory assistance was 5 days (120 hours).
 For weaning all the patients presented VIS < 15.
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RESOLUTION AND FOLLOW UP
Item
Number of patients
Percentage (%)
5
2
1
1
71.42
28.57
14.28
14.28
1
14.28
30 day mortality
1
14.28
6 month mortality
0
0
Clinical complications:
 Renal Injury
 Arterial oclussion
 Hemothorax
 Subarachnoid hemorrhage
 Intra-abdominal hypertension
syndrome
DISCUSSION Short summary of previous cases reported.
Our experience is similar to what was reported by Jung JS and cols in 2013 and Shahrokh T and
cols in 2004 who suggested ECMO support as an effective therapy for the management of acute
right heart failure. However there are other publications that show the effectiveness for the
extracorporeal circuit in the postoperative of other type of cardiac surgeries such as the ones
reported by Karthigesu A and cols in Malaysia with a patient requiring ECMO after off pump
pericardiectomy, having a successful outcome. International literature support is still lacking.
LEARNING POINTS 3 to 5 points.
1. ECMO support within the first 6 postoperative hours in the context of right heart ventricular failure
has shown to positively impact survival rates at 30 days and 6 months in these patients.
2. Differing systemic anticoagulation by 72 hours or more in these patients has lowered the incidence
of neurologic complications such as (SAH) and lower consumption of hemoderivates from the
blood bank.
3. The VIS application could be useful as one of the parameters for the weaning process (VIS<15)
REFERENCES
1.Shahrokh T, Zuckermann A, Ankersmit J,Wieselthaler G,Rajek A, Laufer G, et al.
Extracorporeal Membrane Oxygenation is Superior to Right Ventricular Assist Device for Acute
RightVentricular Failure After Heart Transplantation. Ann Thorac Surg 2004;78:1644 –9.
2. Jung J, Lee S, Lee k, Sun K. Successful Extracorporeal Membrane Oxygenation for Right
Heart Failure After Heart Transplantationd2 Case Reports and Literature Review.
Transplantation Proceedings, 45, 3147e3149 (2013).
3. Karthigesu A, Leman H, Ghazali H. A case of successful extracorporeal membrane
oxygenation for right ventricular failure following pericardiectomy. Med J Malaysia Vol 70 No 6
December 2015.
4. Gaies M, Gurney J, Napoli M, Gajarski R, Ohye R, Charpie J, et al. Vasoactive–inotropic
score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr
Crit Care Med 2010 Vol. 11, No. 2
Date: August 30th, 2016
Authors: Hernández Mónica*, Vélez Santiago**, Rivera Adriana*, Otalvaro Danery*, Vásquez Mónica*,
Vieco Santiago***.
* Department of Surgery, Division of Cardiothoracic Surgery, Clinical Perfusion of Clinica Cardio VID,
Medellín, Colombia.
**Department of Intensive Care Unit, of Clinica Cardio VID, Medellín, Colombia.
*** Department of Surgery, Division of Cardiothoracic Anesthesia, Cardiovascular Anesthesiology of
Clinica Cardio VID, Medellín, Colombia.
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