A Case Report of Venoarterial ECMO as Salvage Therapy for Prolonged Cardiac Arrest Following Post-Reperfusion Intracardiac Thrombosis During Orthotopic Liver Transplantation

Abstract

In this report we describe the use of intraoperative venoarterial ECMO as salvage therapy in a unique case of post-reperfusion intracardiac thrombosis during liver transplantation with prolonged ACLS and coagulopathy. The limited literature on intraoperative ECMO as salvage therapy in liver transplantation is reviewed.

Extracorporeal Membrane Oxygenation use on Liver Transplantation: An Integrative Review

“…23,26,32,33 Although ECMO is an important source of support for treating cardiorespiratory complications in liver transplantation, it is still an invasive and unconventional treatment with high risk. 12 The device is considered quite controversial, as it can often lead to unfavorable repercussions such as septic shock, 13,18 excessive intraoperative bleeding, 5 infection, 21 renal failure, 19,31 heart failure 31 and internal bleeding. 19,34 Due to the intrinsic risks, the therapeutic modality is a treatment of the last choice and should be carefully evaluated as to its necessity.…”

“…Since it is a last-line treatment, it is difficult to distinguish between deaths resulting from ECMO and deaths that occurred due to the severity of the liver disease, in which the intervention did not influence the evolution. 2,6,12,13,18,19,29,31 It is clear that a large number of case reports compromises the level of evidence of the article, due to the impossibility of evaluating measures of effect. However, the use of ECMO for the management of complications of liver disease is a recent therapeutic modality, with few published studies of impact and adequate sample size.…”

“…20 In four of them, cardiopulmonary resuscitation maneuvers with vasoactive drugs were performed, however, without success. [16][17][18]20 In these, cardiac rhythm resumed after using ECMO, with no major associated complications developed. In another case, cardiac resuscitation was successful before installation, but the patient developed septic shock postoperatively, and died.…”

“…15 Other situations, such as occlusion of important veins in circulatory drainages, such as the brachycephalic, internal jugular, and subclavian veins, have also been evaluated for using ECMO. 5 As for cases of hemodynamic repercussion due to severe post-reperfusion syndrome, six articles reported the issue, with two papers about cardiac arrest, 15,16 while others showed arrhythmia, 17 intracardiac thrombosis, 18 severe pulmonary embolism, 19 and cardiogenic shock. 20 In four of them, cardiopulmonary resuscitation maneuvers with vasoactive drugs were performed, however, without success.…”

A Change of Tide or the Beginning of the End: COVID-19

“…Romano et al 43 present a case of intracardiac thrombosis flowing liver transplantation. ECMO (extracorporeal membrane oxygenation) was used to the rescue, but eventually, the outcome was fatal.…”