A large postoperative left ventricular hemorrhagic contusion and management by prolonged mechanical circulatory support: a case report

Abstract

Dear Editor, We experienced a postoperative traumatic left ventricular hematoma that was incidentally found after establishment of rescue mechanical circulatory support (MCS) following sudden postoperative circulatory collapse in the cardiac intensive care unit (CICU). The patient successfully recovered with aggressive and prolonged mechanical circulatory support. We report this case to share a worrisome clinical experience in an intensive care unit. The 4-month-old patient weighing 6.6 kg diagnosed with tetralogy of Fallot and a small secundum atrial septal defect underwent successful total correction in the operation room. However, when he arrived at the cardiac intensive care unit (CICU), sudden bradyarrhythmia developed, leading to acute circulatory collapse. At that moment, we performed open cardiopulmonary resuscitation and established rescue extracorporeal membrane oxygenation (ECMO, Bio-Medicus , Eden Prairie, MN; PHISIO oxygenator, Dideco, Mirandola, Italy). On the 3rd postoperative day, bedside echocardiography showed an unexplained huge hematoma, which was suspected to abut the posterior wall of the left ventricle (LV) in the pericardial space in the first place. On the same day, however, while performing mediastinal irrigation to control bleeding in the operating room, the suspected intrapericardial mass was confirmed to be a swollen hemorrhagic contusion of the posterior wall of the left ventricle, which was also demonstrated in follow-up cardiac computed tomography (Fig. 1). As diffuse oozing from the LV was occurring, packed Gelfoam with thrombin was applied on the LV wall, and massive mediastinal irrigation followed. For anticoagulation, initially heparin was titrated to maintain an ACT around 160 s, followed by exclusion of heparin since LV contusion was confirmed. Packed RBCs and platelets were transfused to achieve Hb [10 g/dl and platelet counts [80,000/mm. On the 4th postoperative day, the oxygenator was changed to a new one because a thrombus had formed in the old one. The patient was weaned from ECMO on the 7th postoperative day, and the divided sternal ends were gradually pulled to the opposite side with a pair of traction strings, accommodating the huge LV. The sternal wound was finally closed on the 14th postoperative day. The patient was able to be discharged with a little motor hypotonia and then completed rehabilitation therapy. The hemorrhagic contusion of the myocardium that developed during ECMO setup was very unusual. In our case, we suspect that the huge contusional hemorrhage of the LV resulted from the procedures used during open cardiac massage and ECMO cannulation. Hemorrhagic problems and bleeding control are always cumbersome issues during ECMO setup [1, 2]. In this case in particular, the contusional wound of the myocardium kept oozing diffusely. However, packing the thrombogenic agent with Gelfoam and maintaining low ACT [2] were relatively effective and sufficient in this puzzling situation. In general, postoperative myocardial edema is decompressed by opening the sternum and covering the wound with a Gore-Tex patch or other materials [3]. However, in our case, the LV was too large to apply