Veno-arterial extracorporeal membrane oxygenation as a perioperative support to redo cardiac surgery for inoperable adult patients: a case series

Abstract

Background: The present article describes three cases of patients in cardiogenic shock (CS) with previous cardiac surgery that made them initially inoperable. Perioperative support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) improved haemodynamic status and results in these high-risk patients.

Case summary: Case 1 is a 57-year-old male morbidly obese with previous aortic valve replacement (AVR) who presented with chest pain and developed cardiac arrest. Cardiopulmonary resuscitation and femoral VA-ECMO were initiated. Three days later, a redo AVR was performed. Veno-arterial extracorporeal membrane oxygenation was maintained for 12 days, followed by 7 days of veno-venous ECMO for complete recovery. Case 2 features a 39-year-old male with two previous mitral valve replacements (MVRs). The first is due to papillary muscle rupture, and the second is due to endocarditis of the mitral prosthesis. He presented with CS and pulmonary oedema. Emergency surgery was performed and the patient was then placed in VA-ECMO. Weaning off was achieved 3 days after surgery. Case 3 is a 21-year-old female with a previous MVR due to rheumatic disease. She presented with CS, severe mitral prosthesis stenosis, and a pulmonary embolism. Femoral VA-ECMO was initiated, and one day later, she underwent a redo MVR operation. Extracorporeal membrane oxygenation was discontinued 4 days later.

Discussion: Dysfunctional prosthetic valves leading to CS may benefit from a redo cardiac operation supported by a perioperative VA-ECMO to optimize haemodynamic status. Despite the results from risk prediction scores, this approach has the potential to reduce operative mortality in initial inoperable patients and allow a definitive redo cardiac surgery.

Keywords: Cardiogenic shock; Case series; Inoperable; Redo cardiac surgery; VA-ECMO; Valvular disease.

Figure 1

Case 1: (A) Continuous spectral Doppler in transoesophageal echocardiogram and deep transgastric projection of the aortic prosthesis, with high velocities and gradients (peak velocity of 4.8 ms, mean gradient of 59 mmHg, and acceleration time of 90 ms). (B) Short-axis transoesophageal echocardiogram in mid-oesophagus at the level of the aortic valve prosthesis. (C) Bilateral alveolar opacities. (D) Dysfunctional bioprosthetic aortic valve causing cardiogenic shock. AVP, aortic valve prosthesis.

Figure 2

Case 2: (A and B) Transoesophageal echocardiogram in mid-oesophageal projection at the level of the mitral prosthesis. Doppler (A) shows moderate paravalvular leak due to detachment of the posterior mitral ring. (B) Two-dimensional model shows opening and closing of the mitral valve discs. (C) Increase in size of pulmonary hilum due to pre-capillary pulmonary hypertension, pulmonary oedema with bilateral central predominance opacities, and right pleural effusion or thickening. (D) Atrial septal approach for mitral valve replacement: mechanical mitral valve dehiscence due to endocarditis leading to shock.

Figure 3

Case 3: (A) Pulmonary embolism in the artery for the anterior segment of the left upper lobe and apical region of the right upper lobe. (B) Transthoracic echocardiogram in apical four-chamber view. Continuous spectral Doppler of the mitral valve prosthesis (arrow) with high gradients and velocities (maximum velocity of 2.2, mean gradient of 15 mmHg, and mean pressure time of 180 ms). (C) Increased cardiac silhouette. Symmetrical pulmonary hila with prominence of vascular markings. (D) Explanted mitral valve bioprosthesis showing marked thickening of its leaflets and restriction to opening and closure.