Abstract
Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used to aid myocardial recovery in patients with postcardiotomy cardiogenic shock (PCCS), it has been associated with adverse effects. The combined use of VA-ECMO and Impella (ECPELLA) for PCCS, however, has been reported to be efficacious with few reports of thromboembolic events. We present a case of aortic thrombosis with visceral malperfusion during ECPELLA management for PCCS. We performed the Bentall procedure, mitral valve repair, tricuspid annuloplasty, and coronary artery bypass graft on a 73-year-old man admitted with congestive heart failure caused by annuloaortic ectasia, along with severe aortic and mitral regurgitation. VA-ECMO and Impella were required, since the cardiopulmonary bypass weaning was difficult. Impella was removed on postoperative day 4. On postoperative days 5 and 6, laboratory data showed worsening renal dysfunction, lactate levels, and acidosis. Contrast-enhanced computed tomography showed thrombosis in the celiac and superior mesenteric arteries. Aortic thrombectomy was performed. Hyperkalemia, caused by a reperfusion injury, resulted in ventricular fibrillation. Continuous hemodiafiltration improved the hyperkalemia. However, irreversible acidosis progressed, and the VA-ECMO flow rate could not be sustained. On postoperative day 7, the patient died. Perioperative use of Impella for PCCS may be effective in improving postoperative cardiac function. When sudden organ failure is observed after surgery, it is necessary to not only keep the exacerbation of cardiogenic shock in mind, but also the possibility of thrombosis.
Similar content being viewed by others
References
Fux T, Holm M, Corbascio M, Lund LH, van der Linden J. Venoarterial extracorporeal membrane oxygenation for postcardiotomy shock: Risk factors for mortality. J Thorac Cardiovasc Surg. 2018. https://doi.org/10.1016/j.jtcvs.2018.05.061.
Griffith BP, Anderson MB, Samuels LE, Pae WE Jr, Naka Y, Frazier OH. The RECOVER I: a multicenter prospective study of Impella 5.0/LD for postcardiotomy circulatory support. J Thorac Cardiovasc Surg. 2013. https://doi.org/10.1016/j.jtcvs.201201067.
Khorsandi M, Dougherty S, Bouamra O, Pai V, Curry P, Tsui S, Clark S, Westaby S, Al-Attar N, Zamvar V. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Surg. 2017. https://doi.org/10.1186/s13019-017-0618-0.
Fiore A, Gueldich M, Derbel H, Piscitelli M. Aortic thrombosis due to a competitive blood flow with double mechanical circulatory assistance. Eur J Cardiothorac Surg. 2020. https://doi.org/10.1093/ejcts/ezaa015.
Ranc S, Sibellas F, Green L. Acute intraventricular thrombosis of an impella LP 5.0 device in an ST-elevated myocardial infarction complicated by cardiogenic shock. J Invasive Cardiol 2013 25 1–3
Mastroianni C, Pozzi M, Niculescu M, Makri R, Clarissou J, Pavie A, Leprince P. Elective Impella recover LP 5.0 utilization for postcardiotomy low-output syndrome after aortic valve replacement. Int J Cardiol. 2012;155:e27–8.
Kapur NK, Whitehead EH, Thayer KL, Pahuja M. The science of safety: Complications associated with the use of mechanical circulatory support in cardiogenic shock and best practices to maximize safety. F1000Res 2020 https://doi.org/10.12688/f1000research.25518.1
Batsides G, Massaro J, Cheung A, Soltesz E, Ramzy D, Anderson MB. Outcomes of Impella 5.0 in cardiogenic shock: a systematic review and meta-analysis. Innovations (Phila). 2018. https://doi.org/10.1097/IMI.0000000000000535.
Succar L, Sulaica EM, Donahue KR, Wanat MA. Management of anticoagulation with Impella® percutaneous ventricular assist devices and review of new literature. J Thromb Thrombolysis. 2019. https://doi.org/10.1007/s11239-019-01837-6.
Lee MC, Peters C, Rai N, Safani M, Thomas GS. Unfractionated heparin protocol during percutaneous left ventricular mechanical circulatory (Impella) support. J Cardiovasc Pharmacol Ther. 2019. https://doi.org/10.1177/1074248418816322.
Newsome AS, Taylor A, Garner S. Anticoagulation of a percutaneous left ventricular assist device using a low-dose heparin purge solution protocol: a case series. J Pharm Pract. 2020. https://doi.org/10.1177/0897190018822105.
Funding
None.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
K.D and Y.S received an honorarium from Abiomed. The other authors declare that they have no conflict of interest.
Ethical approval
This report was approved by the Institutional Review Board.
Informed consent
Informed consent was obtained from the patient for publication of this case report and accompanying images.
Research field
Artificial lung/ECMO.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Yamana, F., Domae, K., Kawasumi, R. et al. Aortic thrombosis with visceral malperfusion during circulatory support with a combination of Impella and extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. J Artif Organs 26, 330–334 (2023). https://doi.org/10.1007/s10047-023-01382-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10047-023-01382-3