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Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
LETTER TO EDITOR  
Year : 2011  |  Volume : 14  |  Issue : 3  |  Page : 240-242
Use of integrated extracorporeal membrane oxygenator in anomalous left coronary artery to pulmonary artery: Better survival benefit


1 Department of Cardiothoracic and Vascular Anaesthesia, CN Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Cardiothoracic and Vascular Surgery, CN Centre, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication20-Aug-2011
 

How to cite this article:
Singh P, Malhotra Kapoor P, Devagourou V, Bhuvana V, Kiran U. Use of integrated extracorporeal membrane oxygenator in anomalous left coronary artery to pulmonary artery: Better survival benefit. Ann Card Anaesth 2011;14:240-2

How to cite this URL:
Singh P, Malhotra Kapoor P, Devagourou V, Bhuvana V, Kiran U. Use of integrated extracorporeal membrane oxygenator in anomalous left coronary artery to pulmonary artery: Better survival benefit. Ann Card Anaesth [serial online] 2011 [cited 2020 Sep 20];14:240-2. Available from: http://www.annals.in/text.asp?2011/14/3/240/84038


The Editor,

We read with great interest the recent report by Malik et al, [1] on the use of extra corporeal membrane oxygenation (ECMO) in an infant with anomalous left coronary artery arising from pulmonary artery (ALCAPA). In this case, the authors used ECMO as a bridge to recovery when the repeated attempts of weaning from cardiopulmonary bypass (CPB) were unsuccessful. The occurrence of left ventricular dysfunction and mitral valve insufficiency causing congestive heart failure symptoms is not unknown in postoperative patients who undergo repair for ALCAPA. Patients with ALCAPA syndrome have a compromised myocardium due to ongoing ischemia and infarction. We performed a case of ALCAPA and used the integrated ECMO, as described by Chauhan and others [1] in order to prevent further myocardial insult and to achieve a possible better survival benefit.

A 3 months old girl, delivered at gestational age of 42 weeks weighing 3.7 kg was admitted with a diagnosis of ALCAPA and severe left ventricular dysfunction and mild mitral regurgitation. Physical examination revealed heart rate of 138/min, systolic blood pressure of 82 mmHg. The patient received inotropic support of infusion of dobutamine intravenously at the rate of 10μg/kg/hr. Respiratory rate was 48/min with mild respiratory distress. SpO 2 was 98% on room air. Chest X-ray confirmed cardiomegaly. Electrocardiogram showed T-wave inversion in leads 1, 2, V3-V6. Q-wave can be seen in V5 and aVL and ST elevation in V4. Left ventricular hypertrophy was also evident. Echocardiography showed dilated left ventricle with global hypokinesia, mild eccentric mitral regurgitation and fibrotic papillary muscle. Ejection fraction was 5-10%. Left ventricle enddiastolic/ left ventricle endsystolic pressure(LVed/LVes) was 47/42. The arterial blood gas was within normal limits (pH - 7.32, pCO 2 - 48, pO 2 - 93, BE - -1.2, HCO 3 - 20.7, SO 2 - 98, Hb - 11.1, HCT - 31, Ca - 0.84, Na - 132, K - 3.7).

No premedication was administered prior to transfer to the operation theatre (OT). The patient continued to receive the inotropic support during transit. General anesthesia was induced with intravenous ketamine 2 mg/kg, fentanyl 5 μg/kg and rocuronium 0.9 mg/kg. Tracheal intubation was done with 4.5 mm plain endotracheal tube. Anesthesia was maintained with O 2 , air and boluses of fentanyl 1 μg/kg and vecuronium 0.1 mg/kg as needed. Right femoral artery was cannulated with 22G cannula and left femoral vein was cannulated with 20-23-23 triple lumen catheter. Ventilatory strategy was tailored to maintain normocapnia and optimal saturation with minimal tolerable fractional inspired oxygen concentration (FiO 2 ).

Integrated ECMO circuitry was established along with CPB circuit and primed with blood. After achieving activated clotting time of 554sec, CPB was initiated. Myocardial preservation was obtained with cold blood cardioplegia solution. The repair was performed with direct anastomosis of coronary button from pulmonary artery to proximal aorta.

After repair,inj milrinone 1μg/kg/hr was started. Weaning from CPB is not attempted in the operating room in order to avoid further damage to left ventricle which is recovering from chronic ischemia. The ECMO protocol in our institution is as follows: The integrated ECMO-CPB circuit involves a slight modification of the CPB circuit by utilizing the ECMO oxygenator during the CPB. The oxygenator that is routinely a part of CPB circuit is not used because of its short life. The main indication of instituting integrated ECMO in our institution are severe pulmonary hypertension and myocardial dysfunction.

The size of the cannula's used in the venous and arterial cannulation is dependent upon the weight of the patient for e.g. in this patient weighing 3 kg the minimum flows used was 300 ml /min and maximum of 450 ml/min with ECMO 800. The maximum flow is 1200ml/min. The ACT is kept between 180-220 seconds and a hemoglobin 10-12 gm% with adequate blood infusion. If any acidosis is suspected, the pump flows are increased.

We come off on roller pump and not a centrifugal pump, which is a part of the CPB machine. It is a totally closed circuit. This single detachable roller pump is shifted with the patient in the ICU.

On ECMO support, inotropes are tapered to maintain mean arterial pressure of 40-50 mmHg with a central venous pressure (CVP)/left atrial pressure (LAP) of <6 mmHg. With maximal flow rates on ECMO (125-150 ml/kg), the patients are ventilated with fraction of inspired oxygen = 21%, with respiratory rate = 10/min, tidal volume = 6-8 ml/kg, and positive end expiratory pressure (PEEP) = 5-6 cm H 2 O to prevent atelectasis. Body temperature is maintained at 36-37°C by the use of water mattress and convection body warmer. A hemofilter is incorporated in the circuit to enable fluid removal based upon input-output balance at 10-50 ml/kg/hour.

The circulation was switched over from CPB to ECMO circuit and patient was transferred to intensive care unit on ECMO support with open sternum. Blood flow of 350 ml/min using roller pump, gas flow of 200 ml/min with fractional inspired oxygen concentration (FiO 2 ) of 0.6 and nasal temperature of 36.6 was maintained. The activated clotting time (ACT) was maintained between 180-220sec. Inj. Dobutamine 10μg/kg/hr and inj. After repair, at the start of rewarming, Milrinone was started at the dose of 1 μg/kg/hr.

patient was maintaining stable clinical and biochemical parameters on gradually decreasing blood flow rate to 40-50ml/kg while maintaining fluid balance of 0.5ml/kg/hr and skin temperature of 36.1. ECMO support was withdrawn after 1 hr. Heart rate was 160/min, BP- 90/50mmHg, SpO 2 96% on FiO 2 of 0.6. Though ECMO support was withdrawn one hour after arriving ICU, the patient was de-cannulated on 2 nd postoperative day followed by sternal closure, in case we may require ECMO support any further. This was done according to our institutional protocol. Ionotropic support was gradually withdrawn over 72hrs and subsequently the trachea was extubated on 4 th postoperative day.

Fujji et al, [2] have also reported a case of ALCAPA with intraoperative ECMO with successful outcome. Chauhan et al, [3] have suggested that there are higher rates of survival of infants undergoing cardiac surgery when ECMO was initiated in the operating room than when it was initiated in the emergency situation in the postoperative period. The advantages of integrated ECMO-CPB circuit are: 1) No time is lost from decision to initiation of ECMO; 2) Early initiation may prevent end organ damage [3] and 3) With a use of integrated ECMO, Surgical asepsis is maintained and the procedure is cost effective. [3] Similarly Aharon et al, [4] have concluded that early institution of ECMO may decrease the incidence of cardiac arrest and end-organ damage, thus increasing survival in these critically ill patients. However the main disadvantages of integrated ECMO is the risk of bleeding and intracerebral haemorrhage. Mechanical complication like thrombus formation or pump failure can occur. Apart from this, short durability of the components is also a problem.

The risk factors for perioperative death of patients suffering from ALCAPA are, low output syndrome and acute myocardial infarction. When ECMO support is initiated in such patients in postoperative period for supporting a failing heart survival is only 33%. [1] It is concluded that integrated ECMO may be a safer strategy aiding recovery of cardiac function in critically compromised cardiosurgical patients and may enhance survival of the patient.

 
   References Top

1.Malik V, Pandey A, Chauhan S, Airan B. Use of extracorporeal membrane oxygenator support to salvage a infant with anomalous left coronary artery from pulmonary artery. Ann Card Anaesth 2011;14:51-4.  Back to cited text no. 1
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2.Fujji Y, Kasahara S, Kanki K, Mitsui H, Ishino k, Sano S. Successful Intra-postoperative extracorporeal circulatory support with atrial communication for treatment of anomalous left coronary artery from the pulmonary artery: A case report. Acta Med Okayama 2007;61:41-5.   Back to cited text no. 2
    
3.Chauhan S, Malik M, Malik V, Chauhan Y, Kiran U, Bisoi AK. Extracorporeal membrane oxygenation after pediatric cardiac surgery: A 10 year experience. Ann Card Anaesth 2011;14: 19-24   Back to cited text no. 3
    
4.Aharon AS, Drinkwater DC Jr, Churchwell KB, Quisling SV, Reddy VS, Taylor M, et al. Extracorporeal membrane oxygenation in children after repair of congenital cardiac lesions. Ann Thorac Surg 2001;72:2095-102.  Back to cited text no. 4
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Correspondence Address:
Poonam Malhotra Kapoor
Department of Cardiac Anaesthesiology, CN Centre, AIIMS, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.84038

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