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CLEAR FILTERS
Crash and burn – A Bridge to Heart Transplant Using Mechanical Circulatory Support
Session:
Casos Clinicos
Speaker:
Pedro Teixeira Carvalho
Congress:
CPC 2020
Topic:
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Theme:
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Subtheme:
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Session Type:
Comunicações Orais
FP Number:
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Authors:
Pedro Teixeira Carvalho; Ana Vaz; Carla Basílio; Nuno Príncipe; Paulo Mergulhão; Sérgio Gaião; Sofia Silva; Roncon de Albuquerque
Abstract
<p>Background</p> <p>Ventricular failure after acute myocardial infarction (MI) remains the most frequent cause of cardiogenic shock (CS), accounting for more than 80% of cases. The incidence of CS complicating MI is still 3-13% and despite a widespread implementation of early revascularization, that contributed to a mortality reduction to 40-50%, CS remains a leading cause of death in MI.</p> <p>Case Presentation</p> <p>The authors present the case of a 60 year old female patient with a medical history of stage 3 chronic kidney disease, type 2 diabetes mellitus and heart failure with reduced ejection fraction diagnosed after a non ST-segment elevation MI two months prior. At the time she was diagnosed with severe diffuse multivessel coronary disease, with poor distal vessels, not amenable to surgical or percutaneous revascularization. At discharge, she had a left ventricular ejection fraction of 29% and a normal right ventricular (RV) systolic function.</p> <p>The patient was admitted due to re-infarction causing biventricular failure and cardiogenic shock, with multi-organ dysfunction. Given her recent medical history of severe coronary disease not amenable to revascularization, an angiogram was not performed and she was started on inotropic and vasopressor support. The hemodynamic response was poor, which prompted the implantation of venoarterial extracorporeal membrane oxigenation (VA-ECMO). She showed signs of recovery of multiorgan dysfunction and was transferred to a reference centre for cardiac transplantation.</p> <p>The following days were complicated by periods of absence of left ventricular ejection flow, causing pulmonary edema, despite programming minimal VA-ECMO flow for maintenance of organ perfusion and climbing doses of dobutamine already causing electrical instability, so an Impella-CP was implanted for left ventricular unloading. This allowed resolution of pulmonary congestion, recovery of RV systolic function, reduction of inotropic support and suspension of ultrafiltration after recovery of diuresis.</p> <p>Other complications followed: dellirium caused by prolonged imobilization, a urinary tract infection, ventricular fibrillation and recurrent minor hemorrhage from the canulae insertion sites requiring blood transfusions. After 27 days of hospitalization, an extracorporeal left ventricular assist device (Centrimag) was implanted, to minimize hemorrhage and allow physical rehabilitation of the patient. She was successfully weaned of VA-ECMO at the 7<sup>th</sup> day after Centrimag implantation.</p> <p>She successfully underwent heart transplant after 38 days of mechanical circulatory support. She was discharged from the hospital 2.5 months later.</p> <p>Conclusion</p> <p>This case demonstrates the challenges of daily management of a patient receiving mechanical circulatory support and the lifesaving role of VA-ECMO as a bridge for heart transplant in cardiogenic shock patients with biventricular failure.</p>
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