Gaining Valuable Time: Elective Use of Extracorporeal Membrane Oxygenation in the Awake Patient as Bridge to Surgery in Acute Postinfarction Ventricular Septal Defect

Objectives: The most important after postinfarction ventricular septal defect (VSD) is timing of surgery. Reduction in mortality from 50 to 20% can be achieved, if clinical status allows a delay of surgery in the range of seven days. We present five patients, who were stabilized by extracorporeal membrane oxygenation (ECMO) and treated successfully by surgery.

Methods: After multidisciplinary decision making, patients with acute post-infarction VSD receive a veno-arterial (v-a) ECMO for circulatory stabilization for ~7 days in an awake state. Patients stay extubated and minimally mobilized until operation. The venous cannula is placed in the femoral vein, the arterial cannula is implanted through a graft to the right subclavian artery. Anticoagulation is monitored by point-of-care Sonoclot analyzer.

Results: From April 2013 to August 2016, five patients (3 male, 54–80 years) received a v-a ECMO after post-infarction VSD for 6–8 days (175 ± 13 hours). Postoperatively, (4xVSD-patch and aortocoronary bypass, 1x VSD-patch) ECMO was continued (48 ± 23 hours). Before operation all patients were awake during mechanical circulatory support and could be weaned from the ECMO postoperatively. Three patients were extubated (1st, 3rd, 5th day) after v-a ECMO explantation. In two patients a change to v-v ECMO was necessary after 24 and 65 hours. One patient was weaned 14 days later from respirator. One patient died of sepsis on the eighth day after v-v ECMO explantation. Four patients were discharged. As ECMO-related complications two patients showed bleeding from arterial cannulation site requiring surgical intervention. In two patients a tamponade occurred necessitating re-thoracotomy. Four patients developed a delirium, all had signs of critical illness polyneuropathy.

Conclusion: ECMO as a time gaining tool in acute postinfarction VSD is a safe technique regarding today's level of technology, which supports reorganization of myocardial scar and might reduce perioperative mortality. V-a ECMO appears to be tolerable in awake patients allowing minimal mobilization. In the aforementioned setting, we demonstrate a standard treatment after interdisciplinary decision making.