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.