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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 : 2014  |  Volume : 17  |  Issue : 2  |  Page : 175-176
Extracorporeal membrane oxygenator for atrial septal defect!!


1 Department of Pediatric Cardiac Anaesthesia and Intensive Care, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, Maharashtra, India
2 Department of Pediatric Cardiac Surgery Children's Heart Centre, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, Maharashtra, India

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Date of Web Publication1-Apr-2014
 

How to cite this article:
Tailor KB, Kadam SV, Kattana HR, Rao SG. Extracorporeal membrane oxygenator for atrial septal defect!!. Ann Card Anaesth 2014;17:175-6

How to cite this URL:
Tailor KB, Kadam SV, Kattana HR, Rao SG. Extracorporeal membrane oxygenator for atrial septal defect!!. Ann Card Anaesth [serial online] 2014 [cited 2020 Mar 29];17:175-6. Available from: http://www.annals.in/text.asp?2014/17/2/175/129890


The Editor,

Sinus venosus atrial septal defect (SV-ASD) with partial anomalous pulmonary venous connection (PAPVC) is one of the variants of atrial septal defect. Rarely, these cases develop severe biventricular dysfunction not responding to conventional inotropic agent in the post-operative period. We describe the use of extracorporeal membrane oxygenator (ECMO) in a post-operative case of SV-ASD and PAPVC with severe biventricular dysfunction with a favorable outcome. The biventricular dysfunction was considered due to viral myocarditis. A 4-year-old male child, weighing 12 kg, was diagnosed to have SV-ASD, with PAPVC to right atrium with normal biventricular function. The patient's clinical features were exertional dyspnea, history of recurrent cough, cold and fever. Surgery was performed through midline sternotomy with standard perfusion protocol and Del-Nido cardioplegic arrest. ASD closure with rerouting of PAPVC was carried out by two-patch technique. The cardiopulmonary bypass (CPB) and aortic cross clamp times were 113 and 60 min, respectively. Dopamine 5 μg/kg/min was electively started to facilitate weaning from CPB. Transesophageal echocardiography in the post-CPB period showed no residual ASD, no gradient across SVC-RA area and normal biventricular function. The patient was transferred to pediatric cardiac intensive care unit (PCICU) for ventilatory support.

The post-operative hemodynamic parameters remained stable and the child was extubated within 5 h of ICU stay. At 7 h after extubation, the patient developed high-grade fever (103°F) and thrombocytopenia (66,000/μL) with total leucocytes count 20,790/μL. The peripheries became cold and arterial blood gases showed metabolic acidosis and high lactate level. The child was intubated and put back on controlled mode of ventilation and milrinone 0.5 μg/kg/min was started to support the circulation. Samples were sent to rule out infection and antibiotics were stepped up to meropenam. About 4 hours later, due to declining hemodynamic parameters adrenaline and noradrenaline were also started. Transthoracic echocardiography performed showed moderate left ventricular dysfunction and severe right ventricular dysfunction. In spite of maximal inotropic support and fluid management, hypotension and tachycardia persisted and the clinical condition of the child continued to deteriorate and it was decided to initiate an ECMO support. The child was immediately shifted to the operating room and placed on a Veno-Arterial ECMO (Maquet Rota Flow, Maquet PLS Pediatric) and transferred to the PCICU with open sternum. On ECMO support, a blood flow of 2.4 l/min/m 2 using a centrifugal pump with FiO 2 of 60% and temperature of 35.5°C was maintained. During ECMO period, the inotropic agents and ventilatory supports were optimized. Child's blood, endotracheal and urine cultures were negative and the serum was negative for dengue antibodies. The fever persisted in spite of optimal antibiotic therapy; therefore, a provisional diagnosis of viral myocarditis was considered and the child was treated with intravenous immunoglobulin (IVIG) in a dose of 2 g/kg over 24-h infusion. The fever settled rapidly and the ventricular function improved within 2 days. The ECMO support was gradually weaned off over next 24 h. Total duration of ECMO support was 68 h. The child was extubated 3 days after chest closure with minimal inotropic support. Child was discharged from hospital on the 22 nd post-operative day without having any neurological complication.

Published data about the frequency of post-operative fever in cardiovascular surgery are limited and the figure varies from 12% to 73% respectively. [1] Fever is associated with the metabolic response to trauma, systemic inflammatory response to CPB, hypothermia, presence of drainage tubes, drugs, blood transfusion and infections. In our patient, fever developed 12 h after surgery. The presence of fever 48 h after surgery should prompt a diligent search for deep-seated infection. [2] Therefore, blood, endotracheal secretion and urine specimen were cultured to rule out infectious etiology, which came negative after 48 h. Dengue was also considered as the cause, which was negative. In view of negative culture for bacterial infections, viral myocarditis was strongly suspected in our case. Several diagnostic methods, such as cardiac magnetic resonance imaging and endomyocardial biopsy are useful for diagnosing it, but in most of the cases, it is a clinical diagnosis based on exclusion of other infections. [3] Case reports and case series have described dramatic responses to IVIG in adults and children with presumed viral myocarditis. Administrations of IVIG have become common in the management of this condition and have dramatic and immediate response to it. [4]

The ECMO was started to support the failing circulation and biventricular myocardial dysfunction. Data from case series suggest that ventricular assist devices or ECMO may provide a bridge to transplant or to recovery in patients with acute myocarditis. [5] In a case series, Chen et al. [6] reported that 80% of patients who received ECMO therapy were bridged to recovery. Finally, With the ECMO support and IVIG, we could prevent an adverse outcome in one of the simple procedure in current era of pediatric cardiac surgery.

 
   References Top

1.Andrade CL, Olvera S, Reyes PA. Fever and infection after heart surgery. A prospective study of 75 cases. Arch Inst Cardiol Mex 1989;59:487-91.  Back to cited text no. 1
    
2.Pien F, Ho PW, Fergusson DJ. Fever and infection after cardiac operation. Ann Thorac Surg 1982;33:382-4.  Back to cited text no. 2
    
3.Schultz JC, Hilliard AA, Cooper LT Jr, Rihal CS. Diagnosis and treatment of viral myocarditis. Mayo Clin Proc 2009;84:1001-9.  Back to cited text no. 3
    
4.Robinson J, Hartling L, Vandermeer B, Crumley E, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database Syst Rev 2005;1:CD004370.  Back to cited text no. 4
    
5.Bohn D, Macrae D, Chang AC. Acute viral myocarditis: Mechanical circulatory support. Pediatr Crit Care Med 2006;7:S22-4.  Back to cited text no. 5
    
6.Chen YS, Wang MJ, Chou NK, Han YY, Chiu IS, Lin FY, et al. Rescue for acute myocarditis with shock by extracorporeal membrane oxygenation. Ann Thorac Surg 1999;68:2220-4.  Back to cited text no. 6
    

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Correspondence Address:
Kamlesh B Tailor
802, Grace-E, Vasant Oscar, LBS Marg, Mulund-W, Mumbai - 400 080, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.129890

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