Temporary Circulatory Support and Extracorporeal Membrane Oxygenation

Mechanical circulatory support in cardiogenic shock: a critical appraisal

INTRODUCTION

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is a life-threatening condition frequently encounter in patients with multivessel coronary artery disease (MVD).

AREAS COVERED

Despite prompt revascularization, in particular percutaneous coronary intervention (PCI), and therapeutic and technological advances, the mortality rate for CS related to AMI remains high. Differently from hemodynamically stable setting, a culprit lesion-only (CLO) revascularization strategy is currently suggested in AMI-CS patients, based on the results of a recent randomized evidence burdened by several limitations and conflicting results from non-randomized studies. Furthermore, mechanical circulatory support (MCS) devices have raised as a key therapeutic option in CS, especially in case of an early implantation without delaying revascularization and before irreversible organ damage has occurred. We provide an in-depth review of current evidences on optimal revascularization strategies of multivessel CAD in infarct-related CS, assessing the role of MCS devices, and highlighting the importance of shock teams and medical care system networks to effectively impact on clinical outcomes.

EXPERT OPINION

Emerging observational experience suggested that an early implantation of MCS (prior to PCI), the performance of an extensive revascularization and the implementation of shock teams and networks are key factors for improving clinical outcomes.

ECMO for Metabolic Crisis in a Patient with Mitochondrial Disease

Patients with mitochondrial disease exhibit disrupted pyruvate oxidation, resulting in intraoperative and perioperative physiologic derangements. Increased enzymatic conversion of pyruvate via lactate dehydrogenase during periods of fasting or stress can lead to metabolic decompensation, with rapid development of fatal lactic acidosis. We describe the intraoperative management and postoperative critical care of a patient with mitochondrial disease who presented for repair of esophageal perforation following repair of a paraesophageal hernia. His surgery was complicated by the development of metabolic crisis and severe lactic acidosis which became resistant to conventional therapy before ultimately resolving with the initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Successful treatment of cardiac arrest following hysteroscopic surgery using extracorporeal membrane oxygenation: A case report

RATIONALE

Cardiac arrest caused by water intoxication syndrome following hysteroscopic surgery is a rare but life-threatening occurrence. Extracorporeal membrane oxygenation (ECMO) is rarely used to treat water intoxication syndrome in hysteroscopic surgery. Here, we successfully treated a patient with water intoxication syndrome following hysteroscopic surgery with ECMO.

PATIENT CONCERNS

We report a rare case of cardiac arrest during hysteroscopic surgery treated with veno-venous (VV) ECMO.

DIAGNOSIS

Water poisoning syndrome was diagnosed by electrolyte examination, the lowest value of serum sodium was 110.7 mmol/L.

INTERVENTIONS

VV-ECMO was prescribed as a measure after traditional cardiopulmonary resuscitation.

RESULTS

ECMO was successfully evacuated on day 5 and the patient was discharged on day 45.

CONCLUSION

Mastering the hysteroscopic operative techniques and using a bipolar hysteroscopic generator, isotonic fluid, perfusion pressures less than 100 mm Hg, and local anesthesia may reduce the risk of hysteroscopic water intoxication syndrome. During hysteroscopic surgery, patients may experience cardiac arrest and fatal water intoxication syndrome. Even when traditional cardiopulmonary resuscitation is successful, VV ECMO may contribute to the recovery of brain function if oxygenation is not maintained.

Successful cure of a patient with urosepsis using a combination of extracorporeal membrane oxygenation and continuous renal replacement therapy: A case report and literature review

Holmium laser lithotripsy (HLL) is one of the common surgical methods for urolithiasis. It causes minor surgical trauma, but complications are not rare. Extracorporeal membrane oxygenation (ECMO) treatment of sepsis is common, but venoarterial (VA)-ECMO treatment of urosepsis has not been reported yet. In this article, we reported a 67-year-old female patient with refractory septic shock caused by HLL under percutaneous nephroscope, involving breathing, heart, kidney and other organs, and organs support treatment was ineffective for the patient. Finally, we successfully treated the patient under VA-ECMO with continuous renal replacement therapy (CRRT). Combined ECMO and CRRT may provide a solution for addressing refractory sepsis. Here we present the case and review relevant literature, so as to provide a treatment strategy for patients with refractory urogenic sepsis and to reduce the mortality rate.

Venovenous Extracorporeal Membrane Oxygenation Combined with Fiberoptic Bronchoscopy-Assisted CO2 Cryotherapy in the Treatment of Massive Hemoptysis in Pregnancy: A Case Report

Background

Massive hemoptysis in pregnancy is very rare but can be life-threatening for both the pregnant woman and fetus. Extracorporeal membrane oxygenation (ECMO) is extremely rare in the treatment of severe hemoptysis in pregnancy. Here we describe the case of massive hemoptysis in the second trimester of pregnancy successfully treated with a combination of venovenous (VV)-ECMO, and bronchial artery embolization combined with fiberoptic bronchoscopy–assisted CO₂ cryotherapy.

Case Presentation

A 34-year-old patient at 28 2/7 weeks gestation with a history of hemoptysis for 3 days was transferred to our care. Massive hemoptysis completely blocked the trachea and main bronchus, and a ventilator could not carry out ventilation. ECMO was performed immediately when oxygenation was not maintained. A right lower bronchial artery hemorrhage was found by bronchial arteriography under ECMO, and embolization with microcoils and gelatin sponge particles was then performed. An emergency bedside carbon dioxide cryo-thrombectomy was performed under fiberoptic bronchoscopy because of obstruction of the trachea and main bronchus. Endotracheal cryotherapy was repeated (for a total three times) until bronchoscopic evaluation confirmed no obstruction of the trachea and no active bleeding in the airway. On day 7, ECMO was successfully evacuated. On day 15, the patient was extubated. On day 17, the tracheotomy was closed and replaced by nasal oxygen inhalation. On day 20, the patient was discharged from hospital. The patient has had no recurrence of hemoptysis in 3-month follow-up.

Conclusion

VV-ECMO combined with carbon dioxide cryotherapy in the treatment of pregnancy complicated with massive hemoptysis is an effective treatment, when massive hemoptysis completely blocked the trachea.

Extracorporeal membrane oxygenation with continuous renal replacement therapy to treat metformin-associated lactic acidosis: A case report

RATIONALE

Metformin-associated lactic acidosis (MALA) is rarely encountered, but has a high mortality rate, Conventional treatments include hemodialysis or continuous renal replacement therapy (CRRT); however, when the disease progresses to end-stage, cardiac function is significantly inhibited, circulation cannot be maintained, CRRT cannot be tolerated, V-A extracorporeal membrane oxygenation (ECMO) may be the last treatment.

PATIENT CONCERNS

The study report a rare case of MALA in an elderly female patient at the age of 72 who was admitted to hospital because of nausea for 2 days, complicated with systemic fatigue.

DIAGNOSIS

MALA was cofirmed because of patient have increased lactic acid levels, blood pH <7.2, and a history of oral metformin intake.

INTERVENTIONS

Venoarterial ECMO (V-A ECMO) combined with CRRT was initiated when circulation was still not hold after intravenous fluids and 5% sodium bicarbonate were prescribed.

OUTCOMES

V-A ECMO was then terminated after 48 hours when circulation was perserved, CRRT was discontinued when PH and lactic acid level were normal limited. etformin-associated lactic acidosis did not recur during 6 months follow-up.

LESSONS

The incidence of MALA is low, but mortality is very high. Intermittent hemodialysis or CRRT should be performed if the lactic acid level is persistently elevated. When severe circulatory dysfunction occurs and cardiac function is inhibited, V-A ECMO support should be performed immediately to maintain circulation, followed by CRRT, which may be the final measure to treat refractory MALA.

Ultra-high pre-membrane lung oxygen saturation in a patient on veno-arterial extracorporeal membrane oxygenation

A 55-year-old man who suffered from acute myocardial infarction complicated with cardiogenic shock was administered veno-arterial extracorporeal membrane oxygenation. Ultra-high pre-membrane lung oxygen saturation of 93% was observed. Transthoracic echocardiography revealed the presence of patent foramen ovale. The four-chamber view showed that the tip of the cannula was located in the patent foramen ovale, which resulted in a left-to-right shunt. Without adjusting the position of the drainage cannula, the patient was weaned from extracorporeal membrane oxygenation at 136 hours after initiation and survived to hospital discharge.