Case Report
An institutional review board approval and informed consent were waived
for this case report.
A 65-year-old male with a history of arrythmogenic right ventricular
cardiomyopathy (ARVC) diagnosed 20 years ago. He was managed with
anti-arrhythmics and an AICD placed for primary prevention in 2001. He
presented with two month history of progressive fatigue and nausea. He
had an episode of multiple AICD firings at home secondary to monomorphic
ventricular tachycardia (VT). He underwent an unsuccessful VT ablation
but was soon admitted to the hospital again with nausea, hypotension,
and worsening right ventricular function. Patient was initially managed
on a telemetry floor but developed worsening end organ perfusion with
hypotension, nausea, lethargy, along with a rise in his creatinine and
transaminases necessitating transfer to an intensive care unit and
initiation of inotropes. Patient’s heart transplant evaluation had
recently started prior to this decompensation and urgent heart team
discussions were held to develop a plan about his transplant candidacy.
Given his rising pressor requirement and continued end organ
dysfunction, the decision was made to place the patient on peripheral
veno-arterial ECMO via his common femoral vessels and complete an
expedited workup. His right ventricular dysfunction did not allow for
any approved single ventricular durable mechanical support and a total
artificial heart was not feasible given his body habitus. End organ
function improved with peripheral VA-ECMO, however the patient’s
immobility and deconditioning set him up for aspiration pneumonitis and
the decision was made to convert to an alternative approach that would
allow for ambulation and physical rehabilitation.
We made a 3 cm skin incision starting at the level of the sternal notch
and carried it down to the sternum. A partial upper hemi-sternotomy was
made and then teed off at the second intercostal space. Particular
attention was paid to remain extra-pericardial in order to avoid the
risk of pericardial adhesions for his future transplant and potential
tamponade on anticoagulation. The patient was then heparinized to an
ACT above 300 seconds and purse-string sutures were placed proximal to
the innominate artery. Next, a Seldinger technique was used to cannulate
the ascending aorta and the presence of wire into the descending aorta
was confirmed with fluoroscopy. The proximal end of the wire was
brought out through a 1 cm stab incision above the right clavicle. The
tract was serially dilated and an 18Fr EOPA cannula was placed
(Figure 1 ). For the venous access, a .035” guidewire was
inserted in the right internal jugular vein. The position of the wire
was confirmed with fluoroscopy and the tract was serially dilated to
place a 27-French Avalon catheter. Both lumens of the Avalon cannula
were “Y-ed” together to provide inflow to the ECMO circuit and avoid
stasis of either lumen of the cannula. After proper de-airing, the
arterial and venous cannula were connected to the ECMO circuit and flow
was established. The partial sternotomy was closed using two #6
sternal wires and the skin was closed in multiple layers.
Post-operatively, the patient was able to be extubated and ambulated
with physical therapy. He was treated for his combined pneumonitis and
pneumonia with a course of antibiotics and pulmonary toilet before being
successfully transplanted after three weeks of ECMO support.
Intrapericardial adhesions at the time of operation were minimal and the
heart transplantation was unremarkable.