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DP12: INTRAOPERATIVE TEE-GUIDED VV ECMO INTERVENTION IN REFRACTORY POST-CPB RESPIRATORY FAILURE DURING REDO AORTIC ARCH SURGERY
Jonathon T Holt1; Yong G Peng, MD, PhD, FASE2
1University of Florida; 2Department of Anesthesiology, University of Florida College of Medicine
Introduction: Transesophageal echocardiography is an instrumental imaging modality in cardiovascular surgery and demonstrates high sensitivity and specificity. In complex aortic procedures, real-time TEE imaging assists in confirming the preoperative diagnosis, detecting new pathology, adjusting surgical and anesthetic strategies, and evaluating surgical intervention outcomes. Differentiating between causes of hypoxemia post-CPB guides the initiation of proper mechanical support. This case demonstrates the importance of TEE-guided decision-making, leading to initiation of the VV ECMO for refractory pulmonary failure.
Methods: A 64-year-old female, sedated, intubated, and on norepinephrine with severe ventilator-dependent pulmonary insufficiency, arrived from another hospital. Preoperative TEE evaluation showed that there was preserved left ventricular function (ejection fraction 50-60%) and a large pseudoaneurysm that was growing around a prior graft site. However, when the TEE was advanced further, the right radial arterial waveform became flat, and these findings raised concern for an aberrant innominate artery and pseudoaneurysm mass effects. After surgical dissection, these initial findings were confirmed. The patient underwent a total arch replacement that included multi-branch grafting under deep hypothermic circulatory arrest and was separated from bypass.
Results: Post-bypass, the patient began to develop acute hypoxic respiratory failure, which was characterized by peak airway pressures exceeding 37 cm H2O, tidal volumes less than 300mL, and copious amounts of blood airway secretions. Post-bypass TEE had revealed newly depressed biventricular functions with a left ventricular ejection fraction estimated at 30-35% and a notable decline in right ventricular function with the TAPSE decreasing from 1.6 cm pre-bypass to 0.9 cm post-bypass. TEE was utilized to confirm that the cause of deterioration was refractory pulmonary compromise rather than cardiogenic shock, after evaluating that there was no new valvular lesion, aortic complication, or tamponade. The perioperative team initiated VV ECMO after refractory hypoxemia persisted despite maximal ventilatory support and verification that respiratory failure was the primary cause of decline. After establishing the VV ECMO, oxygenation began to improve immediately, and RV function partially recovered (TAPSE 1.3cm).
Discussion/Conclusion: This case demonstrated the importance of TEE-guided physiologic evaluation immediately after being separated from bypass. Clear communication among the operating team ensured that unnecessary cardiac interventions were avoided, and the clinical picture was recognized as refractory respiratory failure. Early recognition of the source of hypoxia from respiratory failure instead of cardiogenic shock is critical in complex aortic surgery, especially in redo procedures that involve infection, mass effects, and severe preoperative pulmonary compromise. Integrated TEE assessment, combined with coordinated multidisciplinary communication, was essential to timely VV ECMO initiation and patient stabilization.