Interact CardioVasc Thorac Surg 2009;8:272-274. doi:10.1510/icvts.2008.189407
© 2009 European Association of Cardio-Thoracic Surgery
Use of extra corporeal membrane oxygenation in the management of sepsis secondary to an infected right ventricle-to-pulmonary artery Contegra conduit in an adult patient
Hunaid A. Vohra,
Ceri Jones,
Nicola Viola and
Marcus P. Haw*
Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Road, Southampton, UK
Received 28 July 2008;
received in revised form 16 September 2008;
accepted 23 September 2008
*Corresponding author. Tel.: +442380 777222; fax: +442380798508.
E-mail address: marcus.haw{at}suht.nhs.uk (M.P. Haw).
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Abstract
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This is the first report in the cardiac surgical literature in a grown-up congenital heart male patient with endocarditis of the Contegra conduit who developed septic shock with cardio-respiratory failure and required treatment with extra corporeal membrane oxygenation (ECMO) in order to stabilize his clinical condition preoperatively.
Key Words: Congenital; Endocarditis; Contegra; Extra corporeal membrane oxygenation
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1. Introduction
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The Contegra conduit is a glutaraldehyde-fixed segment of bovine jugular vein containing a trileaflet venous valve used in reconstructions of the right ventricular outflow tract (RVOT). It is available in different sizes, has sufficient length at both inflow and outflow and is reported to have a favourable haemodynamic performance [1]. The Contegra conduit has shown to be an effective alternative to homografts [2], even in infants and in patients with previous RVOT homograft replacement [3]. Endocarditis of the Contegra conduit, which has been described in the literature with an incidence of <3%, generally requires substitution of the conduit [4]. This is the first report in the literature in a 21-year-old male grown-up congenital heart (GUCH) patient with endocarditis of the Contegra conduit who developed septic shock with cardio-respiratory failure in whom extra corporeal membrane oxygenation (ECMO) was used in order to stabilise the patient's clinical condition preoperatively.
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2. Case report
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A 21-year-old male was admitted to the Accident and Emergency Department of the local hospital with a history of persistent fever, malaise and vomiting for the last five days. He was born with a complex cardiac anomaly (mesocardia with atrial situs solitus, discordant ventriculo-arterial connections, RVOT obstruction, ventricular septal defect [VSD], sub-pulmonary stenosis). He underwent a Blalock–Taussig shunt at one week, Rastelli procedure at four years, revision of Rastelli procedure at 12 years and RVOT Contegra conduit at 18 years. Examination revealed a systolic murmur in the pulmonary area. He was admitted to the hospital but deteriorated significantly over the next three days with signs of severe sepsis, a white cell count of 34.8x109/l, CRP 242 mg/l, significant renal deterioration (serum creatinine 178 µmol/l, estimated GFR 43 ml/min/1.73 m2), hepatic dysfunction with a bilirubin of 264 µmol/l along with deranged coagulation (INR-2.1, APTR-3.2) and a lactate of 4 mmol/l. The BP was 70/40 mmHg. He was commenced on empirical intravenous antibiotics (cefuroxime, metronidazole and gentamicin). As the base deficit was –6.7 mEq/l, lactate-10 mmol/l, requiring increasing doses of noradrenaline (0.2 µg/kg/min), he was transferred to the intensive care unit (ICU). Blood cultures were positive for Staphylococcus aureus and antibiotic therapy was changed to intravenous rifampicin and vancomycin according to sensitivities. Continuous veno-venous haemofiltration (CVVH) was commenced and a transthoracic echocardiogram (TTE) showed large vegetations within the conduit, LV ejection fraction of 45% and RVOT obstruction (peak gradient 60 mmHg) associated with a distended, poor functioning RV. Within 3 h of transfer, the pO2 was 6.6 kPa on 100% FiO2 and, therefore, he was mechanically ventilated. Due to continuing deterioration, veno-arterial ECMO was initiated via a cannula into the right femoral artery and one at the IVC/right atrium junction via the right femoral vein. Blood flow (2.2–2.6 l/min) was adjusted to achieve adequate perfusion, evaluated by base deficit, SaO2 and MvO2. The ventilator settings were reduced to minimise lung damage (PEEP-10 cm H2O, FiO2-0·21–0·3, PIP<25 cm H2O, RR-10/min). Inotropes (adrenaline, dopamine and noradrenaline) were reduced once adequate perfusion was achieved. A trans-oesophageal echocardiogram, 24 h later, showed an improvement in myocardial contractility when the flow was reduced. Surgery was performed 48 h after establishing ECMO using the same arterial and venous cannulae for cardiopulmonary bypass (CPB). A redo-sternotomy was then performed. The heart was arrested with antegrade cold blood cardioplegia. At surgery, the conduit contained huge vegetations (Fig. 1) causing obstruction and was replaced with another 22 mm Contegra® Pulmonary Valve Conduit (Medtronic, Minneapolis, USA). The heart came off CPB easily. TTE performed at day 3 post-op showed good RV function with widely patent RVOT/LVOT. The patient was extubated on day 5 post-op. Antibiotics were continued for six weeks and he was discharged home on day 55 post-op.
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Fig. 1. (a) External view of the explanted Contegra conduit. (b) Contegra conduit incised longitudinally showing large vegetations.
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3. Discussion
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ECMO has historically been used almost exclusively in paediatrics, although cases of successful use of ECMO in adults have been reported [5]. In our patient, the clinical picture was complicated by the huge vegetations causing RVOT obstruction, leading to low cardiac output (CO) with poor RV function. Furthermore, multi-organ dysfunction and the previous history of five sternotomies made immediate surgery very high risk. Thus, ECMO was used as a bridge to a definitive procedure. At the end of surgery, ECMO was kept on stand-by, in case it was required straight after CPB. The role of ECMO has also been proposed as a bridge to recovery in patients with severe sepsis, who would otherwise die as a result of either hypoxaemia or inadequate CO [5]. The potential benefits of ECMO in sepsis are a result of temporary cardiovascular/respiratory support, improving perfusion and oxygenation until septicaemia and the overt inflammatory response subside. Ferdman et al. [6] report favourable outcomes in three children who presented with cardiovascular compromise and LV dilatation due to gram-positive sepsis. Another paper, in nine children with refractory septic shock, showed that inotropes could be stopped within 24 h of starting ECMO [7]. In the surgical literature, Ko et al. have reported a good recovery in a 49-year-old patient after 48 days on ECMO instituted for septic shock post-liver abcess drainage [8]. We recently used ECMO successfully as a bridge to recovery in an 18-year-old male who developed sepsis after repair of pectus carinatum. The American College of Critical Care Medicine has presented a consensus on indications for ECMO [9]. For paediatric patients, they recommend only to ‘consider ECMO’ for persistent catecholamine-resistant shock failing directed therapies. There are currently no universally agreed guidelines for use of ECMO in the GUCH population. However, criteria published by experienced centres recommend ECMO in adult patients with combined cardio-respiratory compromise that is life threatening [10].
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4. Conclusion
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We recommend that ECMO should be strongly considered in GUCH patients with multi-organ failure secondary to septic shock who require surgery. The present case report highlights the need for further investigation into the potential of ECMO to treat GUCH patients with refractory septic shock who are at very high risk of surgery.
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References
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Abstract
1. Introduction