Case 2
A 73-year-old female presented with a 4-hour history of chest pain. Electrocardiogram showed an anterolateral ST-elevation MI. Coronary angiogram demonstrated complete occlusion of the mid-anterior descending artery and 60% stenosis of the obtuse marginal branch. Thrombectomy and DES deployment were performed with excellent angiographic results. TTE revealed global biventricular hypokinesis (EF 30%), apical septal akinesis, and a large mid-septal VSD with multiple left-to-right jets (Figure 1C). The patient rapidly developed cardiogenic shock with rising lactate (3.0 mmol/L) and underwent placement of an intra-aortic balloon pump (IABP) and femoral VA-ECMO. Three days later, TTE showed minimal aortic valve opening and root stasis, thus she was switched to central cannulation.
The patient underwent IABP removal and conversion to central ECMO with an LV apical vent (18-Fr aorta, 24-Fr RA, 22-Fr LV apex), as in Case 1. She was extubated on postoperative day 3 and participated in ambulatory rehabilitation. She remained hemodynamically stable with normalizing end-organ function for 22 days before undergoing definitive repair.
After establishment of cardiopulmonary bypass and regular cardiac arrest, CentriMag flow was terminated and the three existing cannulas were removed. Saphenous vein graft was used to bypass the obtuse marginal branch. A longitudinal right ventriculotomy was made 1 cm from the LAD and the 2cm anterior VSD was identified in the mid-septum, surrounded by firm fibrotic tissue. We proceeded with a double patch VSD closure via the right ventricle, as in Case 14. No residual VSD was seen on intraoperative TEE. The postoperative course was uncomplicated and the patient was extubated on postoperative day 4. She was discharged to a rehabilitation facility on postoperative day 20 with improving functional status.