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DP06: HEMODYNAMIC SALVAGE OF POST-INFARCTION VSD: A CASE OF SUCCESSFUL DECANNULATION AND EARLY RECOVERY IN A GERIATRIC PATIENT
Josh Langberg, MD1; Kevin Bennett, MD1; Onassis Naim, MD2
1Memorial Healthcare System; 2Envision Physician Services
Post-infarction ventricular septal defect (VSD) is a catastrophic complication of myocardial infarction, carrying a 30-day mortality rate exceeding 90% without surgical intervention, and remaining high (40–50%) even with repair [1]. Intra- and post-operative mortality risk is higher in the geriatric population especially if requiring emergent open surgical intervention after failed percutaneous closure. Literature describing anticipatory anesthetic strategies during catastrophic failure of transcatheter VSD closure in geriatric patients is limited. This case demonstrates that meticulous anesthetic preparation and prompt decision-making can provide conditions for successful salvage of a fatal cardiac event and preserve end-organ reserve.
An 83-year-old female presented with an NSTEMI and muscular VSD (Baseline LVEF 65%, normal RV). During an attempted transcatheter closure, three successive attempts with increasingly larger devices resulted in significant VSD widening and acute tricuspid chordae rupture. The initial anesthetic was managed with large-bore access and pre-procedural arterial monitoring. Upon cardio-mechanic failure (MAP <40 mmHg), rapid resuscitation with pre-prepared norepinephrine and vasopressin infusions allowed for a controlled transition to emergent VA-ECMO (3500 RPM, 2.2 LPM).
The patient returned to the OR the following day for open VSD repair and tricuspid valve replacement (total bypass time 2.5 hours). Weaning required milrinone, moderate use of pressors, and 2500 units of PCC, 5 bags of pooled platelets, and 4 units of FFP to manage surgical bleeding. On POD 5, the patient returned for ECMO decannulation on epinephrine 2μg/min and was successfully decannulated on epinephrine 3μg/min. A post-decannulation TEE revealed LVEF 41%, improved RV FAC of 28%, and a stable VSD repair with no residual tricuspid regurgitation.
The patient was extubated the following day, mentated well, was on nasal cannula, and participated in physical therapy. However, after initial recovery, the subsequent course was complicated by ATN requiring dialysis, HIT requiring bivalirudin, a spontaneous subdural hematoma, pneumonia, and ischemic colitis leading to lactic acidosis and eventual septic shock. She transitioned to hospice and passed 10 days after decannulation.
Clinical success of this case was predicated on anticipatory hemodynamic management. The decision to have large-bore access and vasopressor infusions available prior to the transcatheter attempt prevented the transition from cardio-mechanic failure to full cardiac arrest. Maintaining a MAP >40 mmHg and avoiding cardiac arrest during transition to VA-ECMO mitigated profound global ischemia, which often complicates urgent/emergent open-heart procedures and carries an independent mortality risk of 10-20% [2].
Achieving post-decannulation RV FAC of 28% and LVEF of 41% while requiring only marginal increases in inotropic support suggests that myocardial stunning was minimized by prompt mechanical circulatory support transition and concurrent maintenance of perfusion [3].
This case highlights that anticipatory anesthetic hemodynamic planning may preserve myocardial and neurologic function during procedural catastrophe, even when ultimate survival is limited by systemic complications and age-related challenges in patient reserve. Future directions may involve earlier implementation of renal-protective strategies or bivalirudin-primed circuits to reduce the secondary inflammatory cascade [4].
References
1. DOI: 10.1016/j.athoracsur.2012.04.020
2. DOI: 10.1016/j.athoracsur.2018.03.003
3. DOI: 10.1016/j.jacc.2018.11.038
4. DOI: 10.1016/j.bpa.2017.10.003