Successful liver failure management using molecular adsorbents recirculating system during complicated veno-arterial extracorporeal membrane oxygenation as a bridge to a left ventricular assist device placement

摘要

Successful liver failure management using molecular adsorbents recirculating system during complicated veno-arterial extracorporeal membrane oxygenation as a bridge to a left ventricular assist device placement. SHIGEKI TABATA, MD, Nicholas Cavarocchi, MD, Hitoshi Hirose, MD. Department of Surgery, Division of Cardiothoracic Surgery Thomas Jefferson University Hospital, Philadelphia, PA Introduction: Extracorporeal membrane oxygenation (ECMO) is a well-established therapy for the patients with cardiogenic shock. We present a patient who developed severe complications while on ECMO. Case presentation: A 49-year-old female presented with severe heart failure and was placed on veno-arterial ECMO for bridge to decision. While on ECMO, the patient developed massive hemoptysis after Swan-Ganz catheter manipulation. After the endotracheal tube was clamped and the patient relied on full ECMO support for 36 hours, the hemoptysis resolved. The patient also developed liver failure with peak total bilirubin of 56 mg/dl. The molecular adsorbents recirculating system (MARS) device was performed from ECMO day 9 to ECMO day 14. Liver function improved and the value of total bilirubin decreased to 9.9 mg/dl on ECMO day 19. On ECMO day 20, the patient underwent a Heart Mate II LVAD placement and successful ECMO wean. During the course of surgical recovery, the patient had two episodes of sepsis and VAD pocket infection, which was finally controlled with antibiotic beads placement into the pocket. The patient was transferred to an acute rehabilitation facility on ECMO day 77. Discussion: Among the many possible hematologic complications, hemoptysis is often difficult to control. In our patient, the hemoptysis was not controllable by conventional treatment, thus the endotracheal tube was clamped to allow the entire airway to tamponade using the advantage of ECMO. Liver function is most important risk factors to determines patient survival. The MARS is a cell-free extracorporeal liver support device which eliminates albumin-bound substances, such as bilirubin. Using MARS, the patient recovered liver function to allow to perform LAD placement safely. While these mechanical circulatory support, control of sepsis isolating the source of infection was essential for patient survival.