Case 1
A 53-year-old male presented to an outside hospital with a 3-hour
history of chest pain. Electrocardiogram showed an inferior ST-elevation
MI. Coronary angiography revealed 100% mid-right coronary artery
occlusion and a single drug-eluting stent (DES) was placed, as flow
could not be restored distally. Given good collateral flow with
preserved ejection fraction (EF 50%), he was discharged after 2 days.
He developed recurrent chest pain and was readmitted 3 days later in
cardiogenic shock. Coronary angiography was unchanged with patent DES.
Transthoracic echocardiography (TTE) revealed normal left ventricular
function, severely depressed right ventricular function, hypokinetic
inferolateral wall, and a 2cm VSD at the inferior mid-septum with
left-to-right shunting (Figure 1A). Given his worsening cardiogenic
shock, femoral venoarterial extracorporeal membrane oxygenation
(VA-ECMO) was initiated prior to transfer to our institution.
The patient arrived intubated with minimal pulsatility and a non-opening
aortic valve with root stasis, requiring urgent conversion to central
ECMO. Intraoperative transesophageal echocardiography (TEE) demonstrated
a posterior VSD and aortic root thrombus (Figure 1B). The ascending
aorta and right atrium were exposed through a right anterior
mini-thoracotomy at the second intercostal space and the LV apex was
exposed through a left anterior mini-thoracotomy at the fifth
intercostal space (Figure 2). The ascending aorta and right atrium were
cannulated with a 21-Fr arterial and 24-Fr venous cannula, respectively.
Both cannulas were tunneled and exteriorized at the right upper chest.
The LV apex was cannulated with a 24-Fr venous cannula and tunneled out
to the left upper abdomen. LV apex and right atrial cannulas were
connected with a Y-connector as inflows. All cannulas were connected to
the CentriMag (Abbott Laboratories, Abbott Park, IL) and an oxygenator
was spliced into the circuit. The femoral cannulas were removed. He was
extubated on postoperative day 1 and participated in ambulatory
rehabilitation. The patient remained on CentriMag support for 20 days
with improving end-organ function before undergoing VSD closure.
After institution of cardiopulmonary bypass with bicaval cannulation,
CentriMag flow was terminated and the existing cannulas removed. A
double patch VSD closure was performed via the right
ventricle4. The right ventriculotomy was made 1.5cm
from the mid-posterior descending artery and the VSD was identified,
surrounded by firm fibrotic tissue (Figure 3). Two patches of bovine
pericardium were tailored to the defect. The right ventriculotomy was
closed and the patient came off bypass with inotropic support. TEE
revealed EF 30-35%, mildly decreased RV function, and no residual
shunt. The postoperative course was uncomplicated and he was discharged
home on postoperative day 12 with good functional status.