An Acute Type A Aortic Dissection Complicated with Malperfusion of the Left Main Coronary Artery / 日本心臓血管外科学会雑誌

A 64-year-old woman was admitted to our hospital with sudden chest and back pain. Computed tomography showed acute type A aortic dissection complicated with malperfusion of the left main coronary artery (LMT). Immediately after the CT, the patient went into sudden shock. Electrocardiogram showed ventricular tachycardia and ventricular fibrillation. Percutaneous cardio-pulmonary support was administered and coronary arteriogram (CAG) was performed. CAG revealed LMT stenosis and intravascular ultrasound showed mobile intimal flap at the LMT. Percutaneous coronary intervention of the LMT was performed. The patient recovered from shock and was treated with ascending aorta replacement with CABG. The patient was discharged from the hospital without any major complication.

Re-expansion Pulmonary Edema after Mitral Valve Plasty via Small Right Thoracotomy / 日本心臓血管外科学会雑誌

We report a case of re-expansion pulmonary edema (REPE), which complicated mitral valve plasy via right small thoracotomy. A 56-years old man underwent mitral valve plasty for severe mitral regurgitation caused by P2 prolapse. After separation from heart-lung machine, massive yellow foamy secretion has begun to spout from the right side endotracheal tube and hypoxemia has ensued. Differential ventilation with high airway pressure and steroid pulse therapy could not counteract the exacerbation of hypoxemia. Echocardiography showed severe diffuse hypokinesis of left ventricular wall. Intra-aortic balloon pumping and percutaneous cardiopulmonary support (PCPS) were introduced, and they were very effective. After five-days' support, PCPS was successfully weaned. The patient recovered well. REPE complicated by mini-thoracotomy approach cardiac surgery, is rare, but can be fatal.

Clinical Outcomes of Patients with Acute Myocardial Infarction Complicated by Severe Refractory Cardiogenic Shock Assisted with Percutaneous Cardiopulmonary Support

PURPOSE: Limited data are available on the role of percutaneous cardiopulmonary support (PCPS) for the treatment of acute myocardial infarction (AMI) patients with cardiogenic shock. We investigated the clinical outcomes and predictors of in-hospital mortality after PCPS in patients with AMI complicated by severe refractory cardiogenic shock. MATERIALS AND METHODS: From January 2004 to December 2011, we analyzed data from 96 consecutive AMI patients with cardiogenic shock assisted by a PCPS system. The primary outcome was in-hospital mortality. The predictors of in-hospital mortality were determined by a Cox proportional-hazards model. RESULTS: In-hospital mortality occurred in 51 (53.1%) patients and 58 (60.4%) patients were able to be weaned from PCPS. Cardiopulmonary resuscitation (CPR) was performed in 61 (63.5%) patients before PCPS initiation. On multivariate analysis, age > or =67 years [adjusted hazard ratio (HR), 4.74; 95% confidence interval (CI), 2.27-9.93; p<0.001], CPR (adjusted HR, 2.32; 95% CI, 1.11-4.85; p=0.03), lactate clearance for 48 hours <70% (adjusted HR, 2.50; 95% CI, 1.04-6.05; p=0.041), and unsuccessful revascularization (adjusted HR, 3.57; 95% CI, 1.85-6.90; p=0.002) were independent predictors of in-hospital mortality after PCPS in patients with AMI complicated by cardiogenic shock. CONCLUSION: In spite of PCPS management, AMI patients complicated by severe refractory cardiogenic shock demonstrated high mortality. Older age, CPR, lower lactate clearance for 48 hours, and unsuccessful revascularization were independent predictors of in-hospital mortality.

Thrombolytic Therapy Complemented by ECMO: Successful Treatment for A Case of Massive Pulmonary Thromboembolism with Hemodynamic Collapse

Pulmonary thromboembolism (PTE) is a common clinical condition related to significant mortality. Furthermore, patients with PTE presenting with right heart thrombus show higher mortality due to rapid hemodynamic deterioration. But the optimal treatment of massive PTE is controversial although various methods have been developed and improved. Here, we presented a case of 56-yr-old woman with massive PTE showing hemodynamic collapse, who was successfully treated with extracorporeal membrane oxygenation (ECMO) adjunct to thrombolytic therapy even without thrombectomy. ECMO was useful for resuscitation and stabilization of the cardiopulmonary function. In conclusion, thrombolytic therapy complemented by ECMO may be an effective treatment option for acute massive PTE with hemodynamic instability.

Successful Recovery after Cardiac Arrest from Medically Intractable Coronary Spasm Induced by Ergonovine, Using Percutaneous Cardiopulmonary Support: A Case Report / 대한구급학회지

The ergonovine provocation test is often used in diagnosing variant angina. Most patients with an ergonovine-induced coronary artery spasm respond promptly to intracoronary nitroglycerin administration within 3 to 5 minutes. However, in a few patients ergonovine results in serious cardiovascular complications due to intractable coronary artery spasm. We report a case of a severe and medically intractable coronary spasm induced by ergonovine, followed by cardiac arrest. Aided by percutaneous cardiopulmonary support (PCPS) and mechanical ventilation, the patient could survive after four days of hospitalization despite a recurrent vasospasm. Recovery was largely attributed to full supportive care and the use of PCPS.

Surgical Embolectomy for Acute Pulmonary Thromboembolism / 日本心臓血管外科学会雑誌

Treatment of acute pulmonary thromboembolism (APTE) in patients with hemodynamic instability still remains controversial. We analyzed the outcome and validity of surgical pulmonary embolectomy for APTE. Between January of 2004 to December of 2010, 15 patients underwent emergency surgical pulmonary embolectomy using cardiopulmonary bypass with beating heart. Our operative indications were ; within 7 days from onset, hemodynamic instability, bilateral pulmonary artery obstruction or unilateral obstruction with central clot and right ventricular dysfunction. Ten patients presented in cardiogenic shock, two of whom showed cardiac arrest and required cardiopulmonary resuscitation before operation. One patient required percutaneous cardiopulmonary support. Median follow up period is 33 months (range 3 to 86 months). All patients survived the operation, but 3 patients died in the hospital on post operative day 11 (massive cerebral infarction), day 18 (brain hypoxia) and day 25 (multiorgan failure). Two of them had cardiac arrest and received cardiopulmonary resuscitation before operation. Hospital mortality was 20%. And all patients left the hospital on foot except one patient who had been bedridden by myotonic dystrophy before operation. No patients died or showed symptoms of pulmonary hypertension after discharge. Prompt diagnosis and surgical pulmonary embolectomy before threatening fatal condition improves the outcome of embolectomy.

Percutaneous cardiopulmonary support for the management of recurrent cardiac arrest during scoliosis correction surgery in the prone position: A case report

Effective cardiopulmonary resuscitation (CPR) is difficult for a patient undergoing surgery in the prone position. We report a successful CPR in a prone-positioned patient. This case is the first case report of successful management of recurrent cardiac arrest using percutaneous cardiopulmonary support (PCPS) during a prone-position surgery. A 18-year-old female patient with severe scoliosis underwent a deformity correction surgery. Sudden cardiac arrest occurred immediately after the insertion of a rod in the surgical field for correcting the spine alignment. The patient's position was promptly changed to the supine position, and cardiopulmonary resuscitation was performed. After the return of spontaneous circulation, the second operation was followed after three weeks. During the second operation, cardiac arrest recurrently occurred whenever the rod was inserted. Cardiopulmonary resuscitation was performed in a prone position. After returing of spontaneous circulation, patient was repositioned to a supine position and the PCPS was started. Under PCPS support, the operation was successfully completed in a prone position, and the patient was successfully weaned from PCPS.

Successful use of percutaneous cardiopulmonary support in patients with cardiogenic shock due to myocardial infarction: Report of two cases

Percutaneous cardiopulmonary support (PCPS) is accepted as a very helpful mechanical support available for patients with cardiogenic shock unresponsive to medical treatment and intra-aortic balloon pump (IABP). Although the indication criteria or guidelines for the application of PCPS have not been established, several reports demonstrate that the early initiation of PCPS allows for good clinical outcomes in patients suffering cardiogenic shock. We experienced two patients that required PCPS before and after emergent cardiotomy to correct ventricular septal defect and left ventricular rupture due to myocardial ischemia, respectively. Herein, we report these cases to emphasize that the early application of PCPS is essential to improve the clinical outcomes in patients with severe cardiogenic shock.

Percutaneous Cardiopulmonary Support in Refractory No-Reflow with Cardiogenic Shock after Coronary Stenting in Acute Myocardial Infarction

Coronary no-reflow is defined as inadequate myocardial perfusion of a given coronary segment without angiographic evidence of mechanical vessel obstruction. No-reflow is visualized angiographically as a reduction in thrombolysis in myocardial infarction (TIMI) flow grade and is typically accompanied by chest pain, electrocardiographic changes with ST-segment shift and possible hemodynamic compromise. No-reflow during primary percutaneous coronary intervention (PCI) results in increasing mortality and morbidity. Therefore, treatment of noreflow is associated with improved clinical outcomes. Generally, the treatment of no-reflow is based on pharmacotherapy. In this case, despite maximal pharmacotherapy and intraaortic balloon pump (IABP), refractory no-reflow accompanied with cardiogenic shock was successfully treated with percutaneous cardiopulmonary support (PCPS).

Percutaneous Cardiopulmonary Support (PCPS) for Patients with Cardiopulmonary Bypass Weaning Failure during Open Heart Surgery / 대한흉부외과학회지

BACKGROUND: Recently, percutaneous cardiopulmonary support (PCPS) has been widely used to rescue patients in cardiogenic shock or cardiac arrest. However, patients with cardiopulmonary bypass (CPB) weaning failure during open heart surgery still have very poor outcomes after PCPS. We investigated clinical results and prognostic factors for patients who underwent PCPS during open heart surgery. MATERIAL AND METHOD: From January 2005 to December 2008, 10 patients with CPB weaning failure during open heart surgery underwent PCPS using the CAPIOX emergency bypass system (EBS(R), Terumo Inc, Tokyo, Japan). We retrospectively reviewed the medical records of those 10 patients. RESULT: The average age of the patients was 60.2+/-16.5 years (range, 19~77 years). The mean supporting time was 48.7+/-64.7 hours (range, 4~210 hours). Of the 10 patients, 6 (60%) were successfully weaned from the PCPS While 5 (50%) were able to be discharged from the hospital. Complications were noted in 5 patients (50%). In univariate analysis, long aortic cross clamp time during surgery, mediastinal bleeding during PCPS and high level of Troponin-I before PCPS were significant risk factors. All of the discharged patients are still surviving 34+/-8.6 months (range, 23~48 months) post-operatively. CONCLUSION: The use of PCPS for CPB weaning failure during open heart surgery can improve the prognosis. More experience and additional clinical studies are necessary to improve survival and decrease complications.

Management of cardiogenic shock during cardiac surgery with long-term use of percutaneous cardiopulmonary support: A case report / 대한마취과학회지

Percutaneous cardiopulmonary support (PCPS) provides hemodynamic and pulmonary support simultaneously and is increasingly used in medical practice. However, the presence of extracorporeal circulation and the use of heparin means it is not free of side effects, and use of PCPS for longer than 96 h is associated with poor prognosis. Therefore, along with the decision of when to apply or discontinue PCPS, an integrated team approach between the surgeon and the anesthesiologist to prevent and/ or manage PCPS-related complications is of paramount importance when the patient's physical status mandates prolonged use of PCPS. We hereby report 2 cases addressing successful management of postoperative cardiogenic shock, refractory to pharmacologic support, with early and prolonged application of PCPS in patients who underwent surgical anterior ventricular endocardial restoration and coronary artery bypass surgery.

Management of cardiogenic shock during cardiac surgery with long-term use of percutaneous cardiopulmonary support: A case report / 대한마취과학회지

Percutaneous cardiopulmonary support (PCPS) provides hemodynamic and pulmonary support simultaneously and is increasingly used in medical practice. However, the presence of extracorporeal circulation and the use of heparin means it is not free of side effects, and use of PCPS for longer than 96 h is associated with poor prognosis. Therefore, along with the decision of when to apply or discontinue PCPS, an integrated team approach between the surgeon and the anesthesiologist to prevent and/ or manage PCPS-related complications is of paramount importance when the patient's physical status mandates prolonged use of PCPS. We hereby report 2 cases addressing successful management of postoperative cardiogenic shock, refractory to pharmacologic support, with early and prolonged application of PCPS in patients who underwent surgical anterior ventricular endocardial restoration and coronary artery bypass surgery.

Percutaneous Cardiopulmonary Support for Tracheal Stenosis Caused by Thyroid Mass: A case report / 대한마취과학회지

A 76-year-old woman presented with tracheal stenosis caused by a thyroid mass. Her symptoms included dyspnea and wheezing. Cervical computed tomography scans revealed an 8.5 x 7.8 cm sized mass and a trachea with an internal lumen 4.3 mm in diameter. The mass caused marked stenosis and deviation of the airway. However, it was not clear if the tracheal lumen was invaded by the mass. We predicted that airway management would be problematic, even in the absence of invasion. Options for intubation included small sized endotracheal tube, fiberoptic bronchoscopy-guided intubation, high frequency jet ventilation, and percutaneous cardiopulmonary support (PCPS). We decided to use PCPS to reduce the chance of ineffective oxygenation and related complications. After supplementing PCPS with epidural anesthesia, general anesthesia was performed without complications. The patient underwent surgical removal of the mass. PCPS was discontinued on the day of surgery, and after two weeks of uncomplicated mechanical ventilatory support, the patient was discharged home.

Anesthetic Management of Complete Tracheal Transection using Percutaneous Cardiopulmonary Support System : A case report / 대한마취과학회지

Patients with complete tracheal transection present a considerable challenge to the anesthesiologist. A 38 year-old woman with complete tracheal transection above the aortic arch level due to blunt trauma was taken to the operating room for an attempt at tracheal repair. Anesthetic management was focused on the maintenance of the airway and adequate ventilation. Primary repair of the trachea was carried out under ventilation support via percutaneous cardiopulmonary support system. Until the disrupted trachea was exposed on the surgical field, ventilation was performed using a laryngeal mask. We discuss the anesthetic management strategies and the alternative mode of ventilation.