Case report
A 65-year-old male patient was admitted to the hospital presenting with
acute coronary syndrome. The coronary angiography showed a
hemodynamically relevant in-stent re-stenosis of the left anterior
descending and ramus intermedius artery. The first intervention was done
23 years ago, followed by multiple re-interventions due to recurrent
in-stent re-stenosis in all three coronary vessels. Echocardiography
revealed preserved left ventricular function with reduced RV function.
The tricuspid annular plane systolic excursion (TAPSE) was at 14 mm
without dilatation of the tricuspid valve anulus (28 mm) but signs of RV
dilatation. The approximated systolic pulmonary artery pressure (PAP)
over the tricuspid valve was measured with 100 mmHg plus central venous
pressure. The patient underwent a right heart catheterization which
confirmed the elevated systolic PAP of 90 mmHg with a regular pulmonary
capillary wedge pressure and, following supplementary CT-angiography,
was diagnosed with a precapillary idiopathic type I PAH. Due to his
coronary state with unstable angina but subclinical PAH, the patient has
been indicated for coronary treatment. Without an option for
interventional therapy, the patient was scheduled for urgent minimally
invasive direct coronary artery bypass surgery.
Despite maximal PAH specific preventive measures during induction of
anesthesia, the patient became hemodynamically unstable requiring
cardiopulmonary resuscitation. Return of spontaneous circulation was
achieved shortly using high doses of inotropic agents. Due to no signs
of new acute ischemic heart abnormalities the surgery was postponed, and
due to circulatory instability despite maximal inotropic support
mechanical circulatory support was indicated. Under on-going mechanical
resuscitation, a veno-arterial-venous, respectively pulmonary artery
(PA) ECMO (V-A-V/PA ECMO) was established (Fig. 1) . An inflow
cannula was inserted percutaneously via the right femoral vein (Getinge
HLS 23F, 55 cm; Rastatt, Germany) into the right atrium and an outflow
cannula was inserted into the right femoral artery (Getinge HLS 17F, 23
cm) for initial stabilization. Thereafter, a soft guidewire was placed
percutaneously via the right internal jugular vein through the
tricuspid- and pulmonary valve, with its tip into the PA common trunk
under fluoroscopic control in the catheterization lab. (seevideo demonstration for the percutaneous deployment of the 21F
outflow cannula via internal jugular vein to the pulmonary trunk over an
extra-stiff guide wire and the final result after removing the cannula’s
inner sheath under fluoroscopic vision) The soft guidewire was then
exchanged via a pigtail catheter for an extra-stiff wire
(Lunderquist, COOK Medical, Bloomington, IN).
Finally, a pre-warmed 21F cannula with a multi-hole tip
(Biomedicus 21F, 50 cm, Medtronic, Minneapolis, MN)
was percutaneously inserted over the stiff wire and connected to the
outflow line of the ECMO system with a monitored in-line flow-reducer.(Fig. 2) Thus, while bypassing the acute failing RV, this
cannula acted as a temporary RVAD. Flow rates were optimized by RV
appearance in echocardiography and for anticoagulation the patient
received standardized heparinization. The femoral arterial outflow
cannula could be explanted after 48 h due to the competent left
ventricle using a combination of a suture-mediated percutaneous closure
device (ProGlide, ABBOTT Vascular, CA) and a sandwiching bioabsorbable
closure device (Angioseal, ABBOTT Vascular, CA) by reinsertion of a
guide wire through the cannula for the needed vessel access. Tricuspid
valve and pulmonary valve were without new abnormalities after
decannulation. The remaining oxygenated temporary RVAD was successfully
explanted at day 8 after implantation. Thereafter, the patient recovered
well, was awake and extubated, and could be discharged for further
medical therapy on day 21. After establishment of proper medical therapy
(sildenafil and macitentan) for precapillary idiopathic type I PAH the
patient is doing well, he is currently in NYHA class II one year after
the ECMO therapy and the coronary artery disease was decided for
conservative treatment at present.