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      Direct thrombolysis of multiple thrombi in both right and left heart atrium in a patient on extracorporeal membrane oxygenation support following urgent double-lung transplantation: a case report

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          Abstract

          Background

          Lung transplantation is considered an established treatment for patients with end-stage chronic respiratory failure. Patients with acute respiratory failure requiring respiratory support with invasive mechanical ventilation while awaiting lung transplantation are at high risk of death. Extracorporeal membrane oxygenation (ECMO) has been proposed as an alternative bridging strategy to mechanical ventilation. The shear stress created by the mechanical pumps causes changes in the hematological system in almost all patients treated with ECMO. An antithrombotic strategy to mitigate ECMO bleeding and thrombotic complications is necessary. The use of thrombolytic therapy is recommended for patients with acute symptomatic embolism with associated hypotension or shock. In this setting, the hemodynamic benefits of thrombolytic treatment far outweigh its bleeding risk.

          Case presentation

          This case report describes a 32-year-old woman suffering from lymphangioleiomyomatosis, who underwent urgent double-lung transplantation. This patient was maintained on ECMO preoperatively, perioperatively, and postoperatively due to life-threatening hypoxemia caused by the progression of her pulmonary tissue damage. Multiple thrombi developed in the early postoperative period, in both right and left heart atria. Direct thrombolysis was successfully performed on the first postoperative day.

          Conclusion

          According to the current published literature, direct thrombolysis of thrombi in both right and left atria in a patient supported on ECMO following urgent double-lung transplantation is an extremely rare treatment method. Even when taking into account all of the risks associated with thrombolysis and arteriovenous ECMO support, we found that this technique is very effective and, without a doubt, it saved the life of our patient.

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          Most cited references 24

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          Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock.

          Death to trauma is caused by disastrous injuries on scene, bleeding shock or acute respiratory failure (ARDS) induced by trauma and massive blood transfusion. Extracorporeal membrane oxygenation (ECMO) can be effective in severe cardiopulmonary failure, but preexisting bleeding is still a contraindication for its use. We report our first experiences in application of initially heparin-free ECMO in severe trauma patients with resistant cardiopulmonary failure and coexisting bleeding shock retrospectively and describe blood coagulation management on ECMO. From June 2006 to June 2009 we treated adult trauma patients (n=10, mean age: 32+/-14 years, mean ISS score 73+/-4) with percutaneous veno-venous (v-v) ECMO for pulmonary failure (n=7) and with veno-arterial (v-a) ECMO in cardiopulmonary failure (n=3). Diagnosis included polytrauma (n=9) and open chest trauma (n=1). We used a new miniaturised ECMO device (PLS-Set, MAQUET Cardiopulmonary AG, Hechingen, Germany) and performed initially heparin-free ECMO. Prior to ECMO median oxygenation ratio (OR) was 47 (36-90) mmHg, median paCO(2) was 67 (36-89) mmHg and median norepinephrine demand was 3.0 (1.0-13.5) mg/h. Cardiopulmonary failure was treated effectively with ECMO and systemic gas exchange and blood flow improved rapidly within 2 h on ECMO in all patients (median OR 69 (52-263) mmHg, median paCO(2) 41 (22-85) mmHg. 60% of our patients had recovered completely. Initially heparin-free ECMO support can improve therapy and outcome even in disastrous trauma patients with coexisting bleeding shock.
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            Utilization of catheter-directed thrombolysis in pulmonary embolism and outcome difference between systemic thrombolysis and catheter-directed thrombolysis.

            The aim of the study was to assess the utilization of catheter-directed thrombolysis (CDT) and its comparative effectiveness against systemic thrombolysis in acute pulmonary embolism (PE).
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              The evolution of extracorporeal life support as a bridge to lung transplantation.

              The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation was reported for the first time more than three decades ago; nevertheless, its use in lung transplantation was largely abandoned because of poor patient survival and frequent complications. The outcomes of patients bridged to lung transplantation using ECMO have substantially improved in the last 5 years. Recent advances in extracorporeal life support technology now allow patients with end-stage lung disease to be successfully supported for prolonged periods of time, preventing the use of mechanical ventilation and facilitating physical rehabilitation and ambulation while the patients awaits lung transplantation. This review briefly describes the evolution of ECMO use in lung transplantation and summarizes the available technology and current approaches to provide ECMO support.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2016
                16 June 2016
                : 12
                : 1003-1008
                Affiliations
                [1 ]Department of Anaesthesiology and Intensive Care, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
                [2 ]3rd Surgical Department, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic
                Author notes
                Correspondence: Lukas Pollert, Department of Anaesthesiology and Intensive Care, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06 Prague 5, Czech Republic, Tel +420 224 435 400, Fax +420 224 435 420, Email lukas.pollert@ 123456fnmotol.cz
                Article
                tcrm-12-1003
                10.2147/TCRM.S109033
                4913996
                27366079
                © 2016 Pollert et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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