Abstract
BackgroundMechanical circulatory support is a common practice nowadays in the management of patients after cardiogenic shock due to myocardial infarction. The single or combined use of one or more devices for mechanical support depends not only on the advantage or disadvantage of these devices but also on the timing of use of these devices before the development of multi organ failure. In our case we used more than one tool for mechanical circulatory support during the prolonged and complicated course of our patient with postcardiotomy cardiogenic shock after coronary artery bypass surgery.Case PresentationWe describe the combined use of Impella 5.0 and veno- pulmonary extra corporeal membrane oxygenation (VP-ECMO) for biventricular failure in a 52 years—old man. He presented with cardiogenic shock after inferior wall ST-elevation myocardial infarction. After emergency coronary artery bypass surgery and failure to wean from extracorporeal circulation we employed V-P ECMO and consecutively Impella 5.0 to manage the primarily failing right and secondarily failing left ventricles.He remained hemodynamically stable on both Impella 5.0 and VP-ECMO until Heart Mate II left ventricular assist device implantation on the 14th postoperative day. Right sided support was weaned on 66th postoperative day. The patient remained in the intensive care unit for 77 days. During his prolonged stay, he underwent renal replacement therapy and tracheostomy with complete recovery. Six months later, he was successfully heart transplanted and has completed three and half years of unremarkable follow up.ConclusionsThe combined use of VP ECMO and Impella 5.0 is effective in the management of postcardiotomy biventricular failure as a bridge for further mechanical support or heart transplantation.
Highlights
Mechanical circulatory support is a common practice nowadays in the management of patients after cardiogenic shock due to myocardial infarction
The combined use of VP extracorporeal membrane oxygenation (ECMO) and Impella 5.0 is effective in the management of postcardiotomy biventricular failure as a bridge for further mechanical support or heart transplantation
An intraaortic balloon pump (IABP) was inserted before surgery and myocardial revascularization was accomplished by bypassing the left internal mammary artery to the left anterior descending coronary artery after thrombendarterectomy and saphenous vein grafting to the right coronary artery
Summary
Conservative management of cardiogenic shock due to myocardial infarction is associated with mortality rates up to 50% [1]. An intraaortic balloon pump (IABP) was inserted before surgery and myocardial revascularization was accomplished by bypassing the left internal mammary artery to the left anterior descending coronary artery after thrombendarterectomy and saphenous vein grafting to the right coronary artery. Intra operative TEE control showed no right ventricular improvement so we replaced the directly inserted pulmonary cannula of the V-P ECMO with another cannula inserted through a 8 mm Dacron graft sewn to the main pulmonary artery and tunneled subcutaneously and exteriorized through the old incision for future easy removal under local anesthesia by suture closing the graft. After gradual improvement of the right ventricle as demonstrated by serial TEE echocardiography, V-P ECMO could be explanted on POD 66 During this long ICU stay, the patient underwent hemodialysis for renal insufficiency and tracheostomy for prolonged mechanical ventilation with complete recovery. Six months later the patient underwent orthotropic heart transplantation with uneventful postoperative course; he was discharged from the hospital after 7 months of admission in a good condition, and has completed three and half years of uneventful posttransplant follow up to date
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