|Year : 2022 | Volume
| Issue : 5 | Page : 14-17
Veno arterial extra corporeal membrane oxygenation as a bridge of pulmonary hypertension management post open heart surgery: A case series and literature review
Nada Aljassim, Mohamed Tageldein, Nabeel Almashraki, Mustafa Safi, Omar Al Tamimi
King Fahad Medical City, King Salman Heart Center, Riyadh, Saudi Arabia
|Date of Submission||13-Dec-2022|
|Date of Decision||28-Dec-2022|
|Date of Acceptance||12-Jan-2023|
|Date of Web Publication||04-Feb-2023|
King Fahad Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
Pulmonary arterial hypertension (PAH) in neonates, infants, and with congenital heart diseases (CHDs) is challenging in diagnosis and management with many risk factors. Pulmonary hypertension (PH) may present intraoperatively with failure of weaning cardiopulmonary bypass with increased mean pulmonary pressure to systemic or supra-systemic where time is limited to manage it. We described six cases with VA-ECMO deployment as a bridge of PH Management to reach optimal conservative therapy that was started immediately. The overall survival was 83%.
Keywords: Extracorporeal life support, extracorporeal membrane oxygenation, pulmonary hypertension
|How to cite this article:|
Aljassim N, Tageldein M, Almashraki N, Safi M, Al Tamimi O. Veno arterial extra corporeal membrane oxygenation as a bridge of pulmonary hypertension management post open heart surgery: A case series and literature review. Saudi Crit Care J 2022;6, Suppl S1:14-7
|How to cite this URL:|
Aljassim N, Tageldein M, Almashraki N, Safi M, Al Tamimi O. Veno arterial extra corporeal membrane oxygenation as a bridge of pulmonary hypertension management post open heart surgery: A case series and literature review. Saudi Crit Care J [serial online] 2022 [cited 2023 Mar 22];6, Suppl S1:14-7. Available from: https://www.sccj-sa.org/text.asp?2022/6/5/14/369161
| Introduction|| |
Pulmonary arterial hypertension (PAH) in neonates, infants, and children is a complex condition associated with several congenital heart diseases (CHDs) preoperative management, especially in the presence of complex underlying etiologies related to a wide variety of CHDs and limited treatment options. Around 3.2%–8.4% of patients receive venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support after pediatric cardiac surgery. VA-ECMO is a rescue bridge until PAH improves upon treatment initiation post-open-heart surgery.
| Methods|| |
We collected all patients, from neonates to children, who underwent open heart surgery for CHD repair and were diagnosed with severe PAH that required VA ECMO PAH at King Salman Heart Center at King Fahad Medical City in Riyadh, Saudi Arabia, over the past 2 years. PAH is defined as a mean pulmonary artery pressure (mPAP) >25 mm Hg at rest, measured by cardiac catheterization (according to the 2015 European Society of Cardiology European Respiratory Society Guidelines and the Fifth World Symposium on PAH, Nice, France, 2013 and late case with new 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension with mPAP >20 mmHg) or measured intraoperatively by direct needle measurement.
The anesthetist routinely inserted a femoral arterial cannula for arterial systemic blood pressure (BP) measurement in the OR. The PH was confirmed in all cases by direct PAP measurement via insertion of a pulmonary artery needle by the cardiovascular surgeon that connected to a pressure transducer and displayed on the monitor [Figure 1]. Basically, ECMO is initiated with 100-120 ml per kilogram per minute. Then, pulmonary vasodilators were started immediately on ECMO with more than three agents, including Milrinone, intravenous Sildenafil, and intravenous Epoprestenol. After that, ECMO flow was reduced to 50%, providing full mechanical ventilatory support with end-tidal carbon dioxide monitoring.,
|Figure 1: Shows 2 monitor screens. On the top screen, patient (#1) with PAP (yellow color wave) almost equal to systemic pressure (red color wave) on day 2 of VA-ECMO. On the bottom screen, patient (#2) with PAP (yellow color wave) equal to half systemic pressure (red color wave) at the end of ECMO after PH management. VA-ECMO: Venoarterial extracorporeal membrane oxygenation, PAP: Pulmonary artery pressure|
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| Results|| |
We collected six patients with different CHD that required open heart surgery. We described the patients' characteristics in [Table 1]. Some patients have risk factors for PH before surgery, like late repair of truncus arteriosus (TA) and prolonged hypoxemia, on top of risk factors developed from cardiopulmonary bypass. None of the patients were diagnosed with PH preoperatively except one (patient #4) in table 1, who developed refractory PH with differential cyanosis that required emergent surgery. The other patients were diagnosed with severe PH intraoperatively associated with the inability to wean cardiopulmonary bypass and extremely low cardiac output, requiring more than two high vasoactive medications. [Table 1].
|Figure 2: End-tidal CO2 trending up on weaning VA-ECMO. VA-ECMO: Venoarterial-extracorporeal membrane oxygenation|
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All patients had systemic or supra-systemic pressures with mPAP >40 mmHg, refractory to inhaled nitric oxide and milrinone in the OR. All patients required VA-ECMO inside the OR via central cannulation with full ECMO flow for 24-48 hours.
We observed that noninvasive end-tidal carbon dioxide (Et-CO2) trend monitoring correlated with invasive PAH improvement and helped to titrate pulmonary vasodilators throughout the patients' course. The average ECMO days were 3. The survival rate was 83%, except for one patient who died post-ECMO decannulation due to a severely low cardiac output [Table 2]. The patients were weaned from pulmonary vasodilator after trial off ECMO over 1-2 weeks and discharged home on oral pulmonary vasodilator medications.
| Discussion|| |
VA-ECMO is a rescue therapy for patients with CHD that acts as a bridge for recovery in post-cardiac surgery PH crises, which lead to weaning cardiopulmonary bypass failure. VA-ECMO can be continued until PH is controlled with optimal conservative therapy of pulmonary vasodilator drugs. However, it is associated with high mortality, especially if ECMO is connected after the cardiac collapse or as extracorporeal cardiopulmonary resuscitation. Therefore, PAH must be managed and controlled efficiently and timely to wean and remove ECMO support as soon as possible.
Several advanced pulmonary hypertension drugs work through three well-known pathways: endothelin, prostacyclin, and nitric oxide pathways, using different routes of administration. All were utilized during the treatment of our cohort with a combination of upfront aggressive therapy to control pulmonary hypertension and save the patients. Post-ECMO, the medications were weaned from intravenous and shifted to oral therapy for a while, then discontinued either in the hospital or after discharge home.
| Conclusion|| |
PAH in CHD is challenging, with a high mortality rate. Early recognition of patients at particular risk and timely establishment of efficient therapeutic actions are crucial. VA-ECMO should be considered early as a bridge for optimizing severe PAH management. Future work to have clear guidelines for managing severe PAH post open heart surgery requiring VA-ECMO in neonates and children is required. Et-CO2 trends monitoring can give a clue for PAH improvement upon weaning ECMO.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hansmann G. Pulmonary hypertension in infants, children, and young adults. J Am Coll Cardiol 2017;69:2551-69.
Kaestner M, Schranz D, Warnecke G, Apitz C, Hansmann G, Miera O. Pulmonary hypertension in the intensive care unit. Expert consensus statement on the diagnosis and treatment of pediatric pulmonary hypertension. The European pediatric pulmonary vascular disease network, endorsed by ISHLT and DGPK. Heart. 2016;102 (Suppl 2):ii57-66. doi: 10.1136/heartjnl-2015-307774.
Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, et al.
2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022;43:3618-731.
Sitbon O, Morrell N. Pathways in pulmonary arterial hypertension: The future is here. Eur Respir Rev 2012;21:321-7.
Baslaim G, Bashore J, Al-Malki F, Jamjoom A. Can the outcome of pediatric extracorporeal membrane oxygenation after cardiac surgery be predicted? Ann Thorac Cardiovasc Surg 2006;12:21-7.
Ghez O, Feier H, Ughetto F, Fraisse A, Kreitmann B, Metras D. Postoperative extracorporeal life support in pediatric cardiac surgery: Recent results. ASAIO J 2005;51:513-6.
[Figure 1], [Figure 2]
[Table 1], [Table 2]