Left ventricular thrombus associated with arteriovenous extra corporeal membrane oxygenation

Successful treatment of veno-arterial extracorporeal membrane oxygenation complicated with left ventricular thrombus by intravenous thrombolysis: A case report

BACKGROUND

Left ventricular thrombus is a rare condition, for which appropriate treatments are not extensively studied. Although it can be treated by thrombectomy, such surgery can be difficult and risky, and not every patient can tolerate the surgery.

CASE SUMMARY

We report a case of a middle-aged man receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for acute myocardial infarction who developed left ventricular thrombus despite systemic anticoagulation. After systemic thrombolysis with urokinase, the left ventricular thrombus disappeared, ECMO was successfully withdrawn 9 days later, and the patient recovered and was discharged from hospital.

CONCLUSION

Systemic thrombolysis is a treatment option for left ventricular thrombus in addition to anticoagulation and thrombectomy.

Pulmonary Protection from Left Ventricular Distension During Venoarterial Extracorporeal Membrane Oxygenation: Review and Management Algorithm

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in adults for refractory cardiogenic shock has risen exponentially during the prior decade. Although VA-ECMO provides cardiopulmonary support, it can alter left ventricular (LV) loading conditions leading to LV distension, which makes the lungs susceptible to congestion and promotes intracardiac thrombosis. These conditions can be alleviated by pharmacologic and mechanical unloading, but gaps in knowledge remain on optimal timing and methods of this approach. This review provides an overview of the epidemiology of VA-ECMO, describes pathophysiology and methods for monitoring and reducing LV loading and summarizes contemporary studies examining the association between LV unloading and adverse events. We offer a simple protocol for implementing LV unloading during VA-ECMO to provide pulmonary protection and improve outcomes.

CPR and ECMO: The Next Frontier

Cardiopulmonary resuscitation (CPR) is a first-line therapy for sudden cardiac arrest, while extracorporeal membrane oxygenation (ECMO) has traditionally been used as a means of countering circulatory failure. However, new advances dictate that CPR and ECMO could be complementary for support after cardiac arrest. This review details the emerging science, technology, and clinical application that are enabling the new paradigm of these iconic circulatory support modalities in the setting of cardiac arrest.

How small is enough for the left heart decompression cannula during extracorporeal membrane oxygenation?

Background

Left ventricular (LV) distension is a recognizable problem accompanied by subsequent complications during venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, no gold standard for LV decompression has been established, and no minimal flow requirement has been designated. Thus, we evaluated the efficacy of the 8-Fr Mullins sheath for left heart decompression during VA-ECMO in adult patients.

Methods

Left heart decompression was performed when severe pulmonary edema was detected on chest radiography or when no generation of pulse pressure followed severe LV dysfunction in patients receiving VA-ECMO. We punctured the interatrial septum and inserted an 8-Fr Mullins sheath into the left atrium via the femoral vein. The sheath was connected to the venous catheter used for ECMO. The catheter was maintained during VA-ECMO.

Results

The left heart decompression procedure was performed in seven of 35 patients who received VA-ECMO between February 2017 and June 2018. Three patients had acute myocardial infarction; three, fulminant myocarditis; and one, dilated cardiomyopathy. Four patients showed noticeable improvement of pulmonary edema within 3 days, and three patients with a pulse pressure of <10 mm Hg showed an increase in pulse pressure of >20 mm Hg within 24 hours from the left heart decompression procedure. All seven patients were successfully weaned from VA-ECMO. No complications related to the left heart decompression procedure occurred.

Conclusions

An 8-Fr sheath may be a possible option for left heart decompression in adult patients with LV distension under VA-ECMO who are expecting recovery of LV function.

Hurdles to Cardioprotection in the Critically Ill

Cardiovascular disease is the largest contributor to worldwide mortality, and the deleterious impact of heart failure (HF) is projected to grow exponentially in the future. As heart transplantation (HTx) is the only effective treatment for end-stage HF, development of mechanical circulatory support (MCS) technology has unveiled additional therapeutic options for refractory cardiac disease. Unfortunately, despite both MCS and HTx being quintessential treatments for significant cardiac impairment, associated morbidity and mortality remain high. MCS technology continues to evolve, but is associated with numerous disturbances to cardiac function (e.g., oxidative damage, arrhythmias). Following MCS intervention, HTx is frequently the destination option for survival of critically ill cardiac patients. While effective, donor hearts are scarce, thus limiting HTx to few qualifying patients, and HTx remains correlated with substantial post-HTx complications. While MCS and HTx are vital to survival of critically ill cardiac patients, cardioprotective strategies to improve outcomes from these treatments are highly desirable. Accordingly, this review summarizes the current status of MCS and HTx in the clinic, and the associated cardiac complications inherent to these treatments. Furthermore, we detail current research being undertaken to improve cardiac outcomes following MCS/HTx, and important considerations for reducing the significant morbidity and mortality associated with these necessary treatment strategies.

Acute Bowel Ischemia Associated with Left Ventricular Thrombus and Arteriovenous Extracorporeal Membrane Oxygenation

Indications for extra corporeal membrane oxygenation (ECMO) have expanded in recent years, and it has become an invaluable tool in the care of adult patients in severe cardiogenic shock or respiratory failure. Understanding the physiologic effect of ECMO has also further developed, allowing for improvements in the management of the potential morbidities associated with this technology. Here, we present a case of acute bowel ischemia that developed while the patient was on central venoarterial ECMO.

Review of Venoarterial Extracorporeal Membrane Oxygenation and Development of Intracardiac Thrombosis in Adult Cardiothoracic Patients

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become an indispensable treatment option for adult cardiothoracic patients experiencing acute refractory cardiogenic shock. VA ECMO is not without inherent complications as in-hospital mortality has ranged from 45% to 65% (1-3). Intracardiac thrombosis (ICT) is a rare but life-threatening complication associated with VA ECMO. VA ECMO cases complicated by ICT were searched for using the MEDLINE (PubMed and OVID), Society of Cardiovascular Anesthesiology Headquarters, and Google Scholar databases. Twelve cases of VA ECMO-associated ICT were discovered for review. Indications for VA ECMO were postcardiotomy cardiogenic shock and heart failure. The primary location of thrombus was the left ventricle and aortic root. Majority of the cases did not report subtherapeutic systemic anticoagulation. Two patients survived after the development of ICT. VA ECMO-associated ICT is a devastating consequence with high mortality. The majority of ICT occurred in cases with perceived adequate anticoagulation, but this may not result in complete suppression of the coagulation response. Continued exposure to procoagulant stimuli and worsening ventricular function and intracardiac stasis can shift the balance toward a hypercoagulable state and development of thrombosis.