Extracorporeal membrane oxygenation as a bridge to definitive repaire in ischemic Ventricular septal defect complicated by cardiogenic shock

INTRODUCTION:

The incidence of Ventricular septal defect (VSD) following ST-segment elevation MI has decreased to 0.17-0.31% due to early primary percutaneous intervention. Surgical repair is the definitive treatment with 30 days mortality of 42.9%. The mortality rate is even higher in patient unstable with cardiogenic shock. Early Veno-Arterial Extracorporeal membrane oxygenation (V-A ECMO) especially in patients with cardiogenic shock permit clinical stabilization and delay repair that may allow friable tissue to organize result in better surgical outcome.

OBJECTIVE:

This study details approach to early V-A ECMO in patient with post infarction VSD complicated by cardiogenic shock and points out our preliminary clinical experience.

PATIENTS AND METHODS:

From April 2018 to July 2019, 4 patients were admitted due to post infarction VSD complicated by cardiogenic shock. 3 were males, mean age 68.5±3y. 2 patients had significant three coronary artery disease, in three patients the culprit lesion was the PDA. IABP (intra-aortic balloon pump) was inserted in 3 cases. Mean STS score was 39%.

RESULTS:

Average time on V-A ECMO before surgical intervention was 13.75days.ECMO improved end organ perfusion with dramatic decreased lactate levels and improved urine output. 3 patients underwent surgical repair, one transcatheter septal closure (TSC). 2 patients had concomitant coronary artery bypass grafting surgery additionally; one patient had tricuspid valve replacement.

2 patients weaned and discharged to rehabilitation in good condition. 1 patient survived more than a year. Both had single coronary artery disease and at most moderate Left ventricular dysfunction.

CONCLUSIONS:

Early V-A ECMO in patients with acute VSD and cardiogenic shock stabilized the hemodynamics and improve end organ perfusion. This stabilization enable delayed repair that may enhance surgical results.