Rescue of a case of ventricular septal defect with Eisenmenger syndrome using an extracorporeal membrane oxygenator

Abstract

Clinical Summary A 38-year-old male patient presented with severe respiratory distress. A large VSD with Eisenmenger syndrome had been diagnosed in the patient 2 years previously (Figure 1). A chest x-ray film revealed a pulmonary hemorrhage at the upper lobe of the right lung (Figure 2, A). The patient’s arterial oxygen concentration was extremely low (68%) even with ventilator support of 100% oxygen. A venovenous extracorporeal membrane oxygenator (ECMO) was inserted through the left femoral vein (outflow from the patient) and right jugular vein (inflow to the patient) in an attempt to increase his oxygen saturation. Because of severe mixing of blood across the VSD, the percutaneous saturation was still low (SpO2 74%) even with the venovenous ECMO support. Intermittent bradycardia occurred during the support, which was considered to be the result of inadequate tissue oxygenation. It seemed critical to find a way to decrease the mixing of deoxygenated blood across the VSD to save the patient’s life. Two days later, after a discussion with the patient’s family, we decided to perform an operation to close the VSD and create an atrial septal defect (ASD) with the use of cardiopulmonary bypass and aortic crossclamping. To prevent right-sided heart failure after the open operation, myocardial temperature was kept at 37°C with warm antegrade and retrograde cardioplegic solution. The large perimembranous VSD without aortic overriding was closed with a knitted Dacron patch and continuous suture with 4-0 polypropylene. A 1.5 1.5 cm fenestration at the atrial level was created to prevent congestion of the right side of the heart after closure of this large VSD. The operation was completed smoothly without right-sided heart failure developing. The patient was sent back to the intensive care unit with