Intensive Care Med (2014) 40:432–433 DOI 10.1007/s00134-013-3173-8
Navid Madershahian Carolyn Weber Maximilian Scherner Georg Langebartels Ingo Slottosch Thorsten Wahlers
IMAGING IN INTENSIVE CARE MEDICINE
Thrombosis of the aortic root and ascending aorta during extracorporeal membrane oxygenation
Received: 22 April 2013 Accepted: 21 November 2013 Published online: 5 December 2013 Ó Springer-Verlag Berlin Heidelberg and ESICM 2013 N. Madershahian ()) C. Weber M. Scherner G. Langebartels I. Slottosch T. Wahlers Department of Cardiothoracic Surgery, Cologne University Heart Centre, Kerpener St 62, 50924 Cologne, Germany e-mail: [email protected] Tel.: ?49-221-47832405 Fax: ?49-221-47832648
Emergent coronary artery bypass grafting was performed in a 73-year-old male patient due to an interventional left main stem coronary artery dissection. Following the operation the patient had to be put on femoral extracorporeal
Fig. 1 a Transesophageal echocardiography showing the thrombosis of entire aortic root and the proximal part of ascending aorta. b M-mode image demonstrating contrast-
membrane oxygenation (ECMO) due to postcardiotomy cardiogenic shock. ECMO flow was adjusted according to measurements of the mixed venous or central venous saturation of oxygen (target 70 %; 4–4.5 l/min ECMO flow). Anticoagulation with intravenous heparin was guided by the activated clotting time (ACT), which was kept strictly above 140 s throughout the whole period of treatment resulting in partial thromboplastin time levels of between 44 and 65 s. Additionally, the thrombocyte count was between 35 and 75 Gyl throughout the whole period of treatment. A heparin-induced thrombocytopenia was ruled out by testing for platelet factor 4–heparin complexes. Three days later, after failed weaning from ECMO, echocardiography showed severe biventricular failure and thrombosis of the entire aortic root and the proximal part of the ascending aorta (Fig. 1). The patient died as a consequence of long-lasting myocardial ischemia and secondary multiple organ failure. If left ventricular output is not
enhanced mass (arrow) suggestive of aortic thrombus formation. Ao aorta, LA left atrium, LV left ventricle, RA right atrium, Thr thrombus
433
maintained, stasis of blood can occur due to the retrograde blood flow in the ascending aorta during veno-arterial ECMO. This may result in intra- or extracardiac thrombosis. Thus, the target ACT should be adjusted according to the cardiac function. Higher anticoagulation therapy should
be considered with none or worsening left ventricular function during ECMO. In these patients serial echocardiography examinations are mandatory on a daily basis. Conflicts of interest None.
Navid Madershahian Carolyn Weber Maximilian Scherner Georg Langebartels Ingo Slottosch Thorsten Wahlers
IMAGING IN INTENSIVE CARE MEDICINE
Thrombosis of the aortic root and ascending aorta during extracorporeal membrane oxygenation
Received: 22 April 2013 Accepted: 21 November 2013 Published online: 5 December 2013 Ó Springer-Verlag Berlin Heidelberg and ESICM 2013 N. Madershahian ()) C. Weber M. Scherner G. Langebartels I. Slottosch T. Wahlers Department of Cardiothoracic Surgery, Cologne University Heart Centre, Kerpener St 62, 50924 Cologne, Germany e-mail: [email protected] Tel.: ?49-221-47832405 Fax: ?49-221-47832648
Emergent coronary artery bypass grafting was performed in a 73-year-old male patient due to an interventional left main stem coronary artery dissection. Following the operation the patient had to be put on femoral extracorporeal
Fig. 1 a Transesophageal echocardiography showing the thrombosis of entire aortic root and the proximal part of ascending aorta. b M-mode image demonstrating contrast-
membrane oxygenation (ECMO) due to postcardiotomy cardiogenic shock. ECMO flow was adjusted according to measurements of the mixed venous or central venous saturation of oxygen (target 70 %; 4–4.5 l/min ECMO flow). Anticoagulation with intravenous heparin was guided by the activated clotting time (ACT), which was kept strictly above 140 s throughout the whole period of treatment resulting in partial thromboplastin time levels of between 44 and 65 s. Additionally, the thrombocyte count was between 35 and 75 Gyl throughout the whole period of treatment. A heparin-induced thrombocytopenia was ruled out by testing for platelet factor 4–heparin complexes. Three days later, after failed weaning from ECMO, echocardiography showed severe biventricular failure and thrombosis of the entire aortic root and the proximal part of the ascending aorta (Fig. 1). The patient died as a consequence of long-lasting myocardial ischemia and secondary multiple organ failure. If left ventricular output is not
enhanced mass (arrow) suggestive of aortic thrombus formation. Ao aorta, LA left atrium, LV left ventricle, RA right atrium, Thr thrombus
433
maintained, stasis of blood can occur due to the retrograde blood flow in the ascending aorta during veno-arterial ECMO. This may result in intra- or extracardiac thrombosis. Thus, the target ACT should be adjusted according to the cardiac function. Higher anticoagulation therapy should
be considered with none or worsening left ventricular function during ECMO. In these patients serial echocardiography examinations are mandatory on a daily basis. Conflicts of interest None.
