Interact CardioVasc Thorac Surg 2008;7:643-645. doi:10.1510/icvts.2008.175877
© 2008 European Association of Cardio-Thoracic Surgery
Proposal for bail-out procedures - Assisted circulation |
Circulatory support with right ventricular assist device and intra-aortic balloon counterpulsation in patient with right ventricle failure after pulmonary embolectomy
Romuald Langoa,
Maciej Micha Kowalika,*,
Katarzyna Klajbora and
Jan Rogowskib
a Department of Cardiac Anaesthesiology, Medical University of Gda sk, ul. D binki 7, 80-211, Gdask, Poland
b Department of Cardiac and Vascular Surgery, Medical University of Gdask, Poland
Received 16 January 2008;
received in revised form 20 March 2008;
accepted 22 March 2008
*Corresponding author. Tel.: +48 58 349 2483; fax: +48 58 349 2471.
E-mail address: mkowalik{at}amg.gda.pl (M.M. Kowalik).
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Abstract
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Severe pulmonary embolism may lead to acute right ventricular failure despite immediate surgical embolectomy, which is regarded as the treatment of choice after recent CABG surgery. We report a case of a patient with massive pulmonary thromboembolism which resulted in acute right ventricular failure following early surgical embolectomy. Pulmonary embolism developed two days after an elective off-pump CABG surgery. We observed severe circulatory collapse which resulted in cardiac arrest and proved refractory to pharmacological treatment after immediate cardiopulmonary resuscitation. Intra-aortic balloon pumping was used in an attempt to improve hemodynamic performance during surgical skin preparation. After the completion of the embolectomy and failure to wean the patient from CPB, upon clinical signs of low cardiac output and akinetic right ventricle, the decision was made to support its function with a centrifugal pump. The substantial improvement of the right ventricular function observed in the next 24 h allowed weaning the patient from right ventricle support. In spite of hemodynamic recovery, the patient remained in a coma on discharge from the cardiac-surgical ICU after 18 days, and died 10 days later from systemic infection.
Key Words: Pulmonary embolism; Cardiopulmonary resuscitation; Right ventricular dysfunction; Right ventricle assist device; Intra-aortic balloon pumping; Cardiac output low
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1. Introduction
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Deep vein thrombosis (DVT) and pulmonary embolism (PE) represent a serious and often underestimated threat to patients after coronary artery bypass grafting (CABG). However, some patients develop DVT in spite of routine prophylactic anticoagulation treatment [1].
In the case of coronary surgery patients operated off-pump, the incidence of DVT was observed to be even lower than 3%, which was reported in on-pump cases [1]. In patients with acute right ventricular failure due to massive PE after recent major surgery, fibrinolytic treatment carries an increased risk of extensive bleeding while percutaneous catheter procedures were reported to be insufficient [2]. Therefore, in patients after recent CABG surgery, especially those who are hemodynamically unstable, immediate pulmonary embolectomy is regarded as the treatment of choice [1, 3]. We report a case of patient with massive pulmonary thromboembolism after off-pump CABG who rapidly recovered his right ventricular function after application of right ventricular assist device (RVAD) along with intra-aortic balloon pump (IABP) after failure to wean him from CPB for pulmonary embolectomy.
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2. Case report
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An 81-year-old hypertensive patient with stable coronary artery disease and preoperative left ventricular ejection fraction of 45%, underwent elective off-pump CABG. Neither any pre-existing risk factors for DVT, nor symptoms of previous PE were identified. The surgical procedure and recovery from anesthesia were uneventful. The patient received routine DVT prophylaxis, including subcutaneous administration of 2850 U of nadroparine twice daily, instituted 8 h after the surgery and oral administration of 150 mg of acetylsalicylic acid, begun 18 h after surgery. On the first postoperative day he was discharged from the postoperative ICU in a clinically stable condition. The next day, on the first ambulation attempt, an acute circulatory failure developed. Right ventricular dilatation and hypokinesis, together with severe tricuspid regurgitation and dilatation of the pulmonary artery were identified on trans-thoracic echo examination, indicating acute pulmonary embolism. The patient was immediately transferred to the operating theatre for pulmonary thromboembolectomy (Fig. 1). On transfer to the operating theatre cardiac arrest occurred and cardiopulmonary resuscitation (CPR) was performed. After regaining electrical heart rhythm, satisfactory blood pressure could not be restored with catecholamines and volume administration, IABP was introduced during surgical skin preparation, in an attempt to improve the patient's hemodynamic performance. After the commencement of normothermic CPB, recent massive thromboemboli were evacuated on inspection of the right and left pulmonary arteries (Fig. 1). The graft to the left descending artery was revised and, despite its apparently adequate function, an additional venous anastomosis to the left descending artery was performed. The whole procedure was carried out without aortic cross-clamping. During the attempt at weaning the patient from CPB, profound right ventricular failure was observed, which proved refractory to profuse volume administration, pharmacological support with high-dose dobutamine and enoximone, as well as electrical atrio-ventricular pacing. On trans-esophageal echocardiography the patient presented global right ventricular akinesis and impaired left ventricular filling. After an additional 30 min of reperfusion and second failure to wean from CPB, a centrifugal pump (3M SarnsTM Centrifugal System, 3M Health Care, MI, USA) was implanted as RVAD which enabled uneventful weaning from CPB.
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Fig. 1. Thromboembolus presented inside the pulmonary truncus (arrow) at the beginning of embolectomy (top), and after its removal (bottom).
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The substantial recovery of the right ventricular function was observed 24 h following the operation (Table 1), and RVAD was successfully explanted 18 h later, while IABP was removed after the following two days. Unfortunately, despite rapid hemodynamic improvement, the patient remained in a deep cerebral coma which was attributed to inadequate cerebral perfusion on CPR. The early post-operative treatment was otherwise uneventful. The patient was discharged from the ICU on the 18th postoperative day in a stable hemodynamic condition, but died of infection 10 days later in a neurology department. The autopsy revealed multiple ischemic foci in the brain.
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3. Discussion
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Cardiac arrest following massive pulmonary thromboembolism represents an unfavorable pathophysiological condition for hemodynamically effective external chest compressions on CPR. Therefore, with rapid development of acute right ventricular failure following pulmonary embolism, surgical intervention should be instituted without delay, unless a percutaneous cardiopulmonary support system (PCPS) is to be set up [4]. As in the presented patient, where heart arrest occurred on transfer to the operating theatre, there was no time to introduce a PCPS.
Despite successful surgical embolectomy, right ventricular dilatation following massive pulmonary embolism may result in acute right ventricular failure, severe enough to interfere with weaning the patient from CBP. In such setting, acute right ventricular dysfunction can represent reversible pathology and, therefore, it can be regarded as an indication for mechanical support with RVAD or PCPS [4, 5]. The survival rate observed in patients who required RVAD support was much lower in comparison to patients with left ventricular failure supported with left ventricular assist device after CPB [6]. The rationale for our decision was based on severely decreased right ventricular contractility which remained refractory to inotropic support. Right ventricle function was assessed by TEE and direct right ventricle inspection, along with adequate right- but inadequate left ventricular filling (Table 1).
In the presented patient, right ventricle pre-load reduction provided by RVAD enabled early recovery of right ventricular function. The search of literature found only two reports on RVAD support for right ventricular failure treatment after pulmonary thromboembolectomy and one on percutaneous circulatory support during thrombolytic treatment [7–9]. In our opinion, left ventricular afterload reduction and improvement of coronary perfusion with IABP treatment could have contributed substantially to the observed early hemodynamic improvement.
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4. Conclusion
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Decision on implantation of the RVAD was made upon complex clinical evaluation of the right ventricular function, including echocardiography, and hemodynamic collapse unresponsive to inotropic support. The use of a centrifugal pump for mechanical right ventricular support along with the IABP device allowed rapid recovery from acute dilative right ventricular dysfunction resulting from massive pulmonary embolism and presented an effective alternative if PCPS is inapplicable.
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References
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Abstract
1. Introduction