Complications during extracorporeal membrane oxygenation (ECMO) therapy are frequent and are associated with a significant increase in morbidity and mortality, so early recognition and treatment is essential. The difficult balance between the need for anticoagulation and the management of bleeding events is one of the main challenges in the care of patients treated with this therapy. Transesophageal echocardiography (TEE) has become a fundamental tool in the field of anesthesia during cardiovascular surgery (CCV), both for hemodynamic monitoring and diagnosis of possible complications during the perioperative period.
A 33-year-old woman underwent heart transplantation for end-stage heart failure secondary to cyanotic congenital heart disease, with 3 previous corrective surgeries. In the first postoperative hours, she developed severe right ventricular systolic dysfunction requiring placement of ECMO V-A, with 21 French venous cannula and 18 French arterial cannula. During the first few days, she required reoperation on two occasions due to cardiac tamponade, forcing the temporary suspension of anticoagulation. After 10 days of ECMO and due to improvement of right ventricular function, she was transferred to the operating room for removal of the cannulae. During anesthetic monitoring by TEE, and once the venous cannula had been removed, a large thrombus was observed extending from the right atrium to the suprahepatic veins (Figure 1). After evaluating different therapeutic options, medical treatment with systemic heparinization with unfractionated heparin (UFH) was decided. Subsequent ultrasound controls showed the disappearance of the thrombus, After 30 days the patient was discharged from the ICU.
Hemostatic complications, both thrombotic and hemorrhagic, are one of the main complications of ECMO. Sometimes both complications can occur in the same patient, as occurred in the patient presented in this case report. Due to the numerous hemorrhagic complications, during ECMO therapy, it was necessary to suspend UFH therapy on numerous occasions with the consequent deficit in anticoagulation levels, which favored the formation of a large thrombus in the inferior vena cava diagnosed during the intraoperative phase of ECMO withdrawal. TEE constitutes a quality standard in cardiovascular surgery. It is a fundamental tool for both monitoring and diagnosis in the perioperative period, allowing correct surgical planning and assessment of the response of the cardiovascular system to surgical and pharmacological interventions. The latest published guidelines establish that intraoperative TEE should be performed in most cardiac surgery procedures, as well as in the implantation and removal of ventricular assistance and extracorporeal membrane oxygenation
We report a case where the intraoperative use of TEE, during the removal of ECMO cannulae, was essential for the detection and early initiation of treatment of a serious complication, such as extensive thrombosis around the venous cannula.
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