Regístrese
¿Aún no está registrado?
Información relevante

Consulte los artículos y contenidos publicados en este medio, además de los e-sumarios de las revistas científicas en el mismo momento de publicación

Máxima actualización

Esté informado en todo momento gracias a las alertas y novedades

Promociones exclusivas

Acceda a promociones exclusivas en suscripciones, lanzamientos y cursos acreditados

Crear Mi cuenta
Buscar en
Revista Colombiana de Cardiología
Toda la web
Inicio Revista Colombiana de Cardiología Central extracorporeal membrane oxygenation as a bridge to decision in a patient...
Información de la revista
Compartir
Compartir
Descargar PDF
Más opciones de artículo
Visitas
39
Adult Cardiology - Case Presentations
DOI: 10.1016/j.rccar.2017.12.022
Open Access
Central extracorporeal membrane oxygenation as a bridge to decision in a patient with a ventricular septal rupture complicating a myocardial infarction
Análisis de las medidas de prevención secundaria introducidas en pacientes con historia de síndrome coronario agudo
Visitas
39
Eduardo Josué Flores-Umanzor
Autor para correspondencia
ejfu0209@gmail.com

Corresponding author.
, Margarida Pujol-Lopéz, Victoria Martin, Rut Andrea, Marta Farrero
Cardiology Department, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Spain
Este artículo ha recibido
39
Visitas

Under a Creative Commons license
Recibido 21 septiembre 2017, Aceptado 17 diciembre 2017
Información del artículo
Resumen
Texto Completo
Bibliografía
Descargar PDF
Estadísticas
Figuras (1)
Abstract

In the era of primary percutaneous coronary intervention, mechanical complications after acute myocardial infarction are extremely rare, with an incidence of less than 0.5%. Rupture of the ventricular septum is the least frequent occurrence. Despite early surgical repair, mortality still remains high. Patients who are at high risk of perioperative death include those with cardiogenic shock and multiorgan dysfunction. In this group, a mechanical circulatory support such as an Extracorporeal Membrane Oxygenation circuit could be used as bridge to surgical repair is feasible or heart transplantation, as it provides hemodynamic stability and the potential to correct multiorgan dysfunction. We reported a case pf ECMO device implantation as a bridge to heart transplantation in a patient with post infarction ventricular septal rupture. Unfortunately, while on the waiting list for heart transplantation with maximum priority the patient had massive diffuse alveolar hemorrhage secondary to the anticoagulation required by the equipment and died.

Keywords:
Ventricular septal rupture
Extracorporeal membrane oxygenation circuit
Acute myocardial infarction
Resumen

En la era de la intervención coronaria percutánea primaria, las complicaciones mecánicas tras un infarto de miocardio agudo son extremadamente infrecuentes, con una incidencia de menos del 0,5%. La ruptura del septum ventricular es el caso menos frecuente. A pesar de la reparación quirúrgica, la mortalidad sigue siendo elevada. Los pacientes con alto riesgo de muerte perioperativa incluyen a aquellos con shock cardiógeno y síndrome de disfunción multiorgánica. En este grupo, podría utilizarse soporte circulatorio mecánico, tal como el circuito de oxigenación por membrana extracorpórea, como puente hacia la reparación quirúrgica o trasplante cardiaco, ya que aporta estabilidad dinámica y la posibilidad de corregir el síndrome de disfunción multiorgánica. Se reporta un caso de implantación de dispositivo de membrana extracorpórea, como puente al trasplante cardiaco, en un paciente con ruptura del septum ventricular tras infarto. Lamentablemente, a pesar de estar en lista de espera con prioridad máxima, sufrió una hemorragia alveolar difusa masiva, secundaria a la anticoagulación requerida por el equipo, y falleció.

Palabras clave:
Ruptura del septum ventricular
Circuito de oxigenación por membrana extracorpórea
Infarto de miocardio agudo
Texto Completo
Introduction

In the era of primary percutaneous coronary intervention, mechanical complications after acute myocardial infarction (MI) such as post MI ventricular septal rupture (VSR) are pretty rare, with an incidence less than 0.5%. Nevertheless, despite its declining incidence, current mortality remains extremely high- 30-day mortality of 100% with medical treatment and 42.9%, mortality with surgical treatment in current series- and appears mostly unchanged over the last few decades.1,2

In relation to surgical repair the mortality varies significantly depending on timing of surgery with a 54.1% mortality in patients who underwent surgery within 7 days of presentation compared with 18.4% mortality if repair is delayed after 7 days.3 Patients who are at high risk of perioperative death include those with cardiogenic shock and multiorgan dysfunction. In this group a mechanical circulatory support such as an extracorporeal membrane oxygenation (ECMO) circuit could be used as bridge to surgical repair is feasible or heart transplantation, as it provides hemodynamic stability and the potential to correct multiorgan dysfunction.1

Case presentation

A 69-year-old man, current smoker, with previous medical history of systemic arterial hypertension was assisted in his home by the emergency medical service based on intermittent oppressive thoracic pain that had persisted for 48hours. An electrocardiogram revealed sinus rhythm with ST segment elevation and significant Q waves in anterolateral leads - general treatment measures for ST segment elevation myocardial infarction including sublingual nitroglycerin, anticoagulant with unfractioned heparin and dual antiplatelet therapy—were initiated. He was immediately transferred to the cardiac catheterization laboratory for an emergent coronary angiogram. At his arrival to the hospital, the physical examination of the patient revealed a harsh, pansystolic murmur, as well as a palpable thrill without bibasilar pulmonary crackles. Due to the previous finding a VSR complicating MI was suspected. A transthoracic echocardiogram demonstrated drop out of the apical ventricular septum and the presence of flow across the septum using color Doppler confirming the diagnosis of VSR. Severe left ventricular (LV) dysfunction and apical thinning compatible with a pseudoaneurysm were also noted. The right ventricular function was preserved. The previous findings were confirmed by a transesophageal echocardiography (fig. 1A) (Video 1-3: available in on line supplementary material). Three vessel significant coronary artery disease was observed in the coronary angiogram and an intra-aortic balloon pump was implanted to decrease LV afterload with diminishing of the shunt volume and to improve the coronary blood flow. Suddenly, the patient became hemodynamically unstable with multiorgan dysfunction requiring treatment with vasopressors and invasive mechanical ventilation. An emergent cardiothoracic consultation was performed. The Heart Team discussed the case and the surgical option was dismissed because of the large extent of the VSR, possible pseudoaneurysm and coronary artery bypass surgery. A central veno-arterial ECMO was implanted as a bridge to candidacy for heart transplantation with initial hemodynamic improvement achieved (fig. 1B). Unfortunately, while on the waiting list for heart transplantation with maximum priority the patient had massive hemoptysis secondary to diffuse alveolar hemorrhage and died.

Figure 1.
(0,28MB).

A transthoracic and transesophageal echocardiogram demonstrated drop out of the apical ventricular septum (Yellow arrow) and the presence of flow across the septum using color Doppler confirming the diagnosis of VSR. (Blue arrow) Severe left ventricular (LV) dysfunction and apical thinning compatible with a pseudoaneurysm were also noted. Figure 1 B A central veno-arterial ECMO was implanted as a bridge to emergent heart transplantation. The venous access was located at the right atrium and the arterial access at the right femoral artery.

Discussion and conclusion

The use of circulatory support in the form of an ECMO device in post infarction VSR is an adequate option to stabilize patients until surgery, when the cardiac function can be recovered with either primary repair or transplant, and medical treatment to stabilization is unsuccessful, and emergent surgery has prohibitive risk. Rozado et al.4 described a successful case of ECMO device use in post infarction VSR to stabilize patients suffering cardiogenic shock until favorable delayed surgical repair was performed. Pascual et al.5,6 reported the experience of ECMO device implantation as a bridge to successful heart transplantation in an unusual case with 2 mechanical complications of myocardial infarction-a post infarction VSR and LV pseudoaneurysm-considered surgically irreparable.

However, circulatory support in the form of an ECMO device is not free of complications, such as dreadful bleeding secondary to the anticoagulation required by the equipment like in our case or vascular and infectious complications.5

Oxigenación central por membrana extracorpórea, como puente hacia la decisión en un paciente con ruptura del septum ventricular, como complicación del infarto de miocardio

Funding

None.

Conflict of interest

None.

Appendix A
Supplementary data

(0,87MB)
(1,41MB)
(0,63MB)

References
[1]
B.M. Jones, S.R. Kapadia, N.G. Smedira
Ventricular septal rupture complicating acute myocardial infarction: a contemporary review
Eur Heart J., 35 (2014), pp. 2060-2068 http://dx.doi.org/10.1093/eurheartj/ehu248
[2]
Flores-Umanzor, E., Caldentey, G. & San Antonio, R. New holosystolic murmur after acute myocardial infarction. European Heart Journal: Acute Cardiovascular Care 204887261774170 (2017). doi:10.1177/2048872617741708.
[3]
R.S. Kutty, N. Jones, N. Moorjani
Mechanical complications of acute myocardial infarction
Cardiol Clin., 31 (2013), pp. 51931
[4]
Rozado J, Pascual I, Avanzas P, et al. Extracorporeal.
[5]
membrane oxygenation system as a bridge to reparative surgery in ventricular septal defect complicating acute inferoposterior myocardial infarction. J Thorac Dis 2017;9(9):E827-E830. doi: 10.21037/jtd.2017.08.164.
[6]
I. Pascual, F. López, D. Hernández-Vaquero
Circulatory support with extracorporeal membrane oxygenation system as a bridge to heart transplantation in complex postinfarction ventricular septal rupture
Rev Esp Cardiol (English Ed Elsevier, 69 (2016), pp. 617-619
Copyright © 2018. Sociedad Colombiana de Cardiología y Cirugía Cardiovascular
es en pt
Política de cookies Cookies policy Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.