TO THE EDITORS:Intraoperative cardiac arrest is a dreaded complication of liver transplantation with a poor outcome. 1,2 The majority of cardiac arrests occur during the neohepatic phase, especially during reperfusion, and most are caused by either postreperfusion syndrome or pulmonary thromboembolic events. 2 Almost 20% of patients with intraoperative cardiac arrest cannot be successfully resuscitated and do not regain a spontaneous rhythm and circulation. Of those who regain a spontaneous rhythm and circulation with cardiopulmonary resuscitation (CPR), more than 12% will not survive the surgery. The mortality of intraoperative cardiac arrest increases exponentially with the duration of CPR. If spontaneous rhythm and circulation are not restored rapidly, the prognosis is usually poor. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used as an extension of CPR in many clinical scenarios with varying success. We describe a successful case of the use of VA-ECMO to treat postreperfusion cardiac arrest and discuss practical aspects of using VA-ECMO as rescue CPR during liver transplantation. CASE REPORTA 61-year-old man with hepatitis B cirrhosis and hepatocellular carcinoma underwent deceased donor liver transplantation. He had previously undergone transarterial chemoembolization of the hepatocellular carcinoma and esophageal banding for esophageal varices. His physiologic Model for End-Stage Liver Disease score was 8 (serum creatinine 5 0.66 mg/dL, total bilirubin 5 0.9 mg/dL, and international normalized ratio 5 1.2). He was well compensated and reported good exercise tolerance with no symptoms of cardiac disease. A transthoracic echocardiogram 3 months before surgery demonstrated a left ventricular ejection fraction of 60% to 65%, normal biventricular systolic function, and no valvular pathologies. There was no evidence of wall motion abnormalities on a technetium-99m sestamibi pharmacologic stress test, which was also performed 3 months before surgery.A suitable standard criteria donor organ was identified (a 25-year-old woman who had a subarachnoid hemorrhage). The liver graft was procured and coldpreserved in a standard fashion without a perfusion circuit. The cold ischemia time of the graft was 5 hours 15 minutes, and the warm ischemia time was 47 minutes.The recipient was brought into the operating room, and after induction of general anesthesia, left radial and right femoral arterial catheters were placed along with a right internal jugular introducer with a pulmonary artery catheter without any complications. Initial intraoperative laboratory values were unremarkable. The dissection phase proceeded without complications and without the need for blood products. The patient tolerated clamping of the inferior vena cava and removal of the native liver with only low-dose vasopressor support (norepinephrine at 1 mg/minute and vasopressin at 1 U/hour). During the anhepatic phase, the patient remained hemodynamically stable and required slowly increasing doses of vasopressors with peak doses o...

Despite advances in detection and treatment, acute traumatic aortic injury (ATAI) is associated with high rates of morbidity and mortality. Both physical and hemodynamic forces have been postulated as mechanisms of aortic injury during a traumatic event. For patients who survive the initial injury, rapid detection is critical for diagnosis and procedural planning, which requires a thorough knowledge of both its clinical presentation and the available diagnostic imaging modalities. Radiography, computed tomography (CT), and magnetic resonance imaging (MRI) can each have a role in the diagnosis of ATAI.After stabilization of the patient, the management of ATAI is guided by the severity of injury. Appropriately selected patients with low grade injuries may be managed non-operatively. When treatment is required, there are both open surgical and endovascular options. In current practice, endovascular approaches with stentgraft placement are preferred due to their high clinical success and low rates of complications. Complications from endograft placement can include: endoleak, endograft collapse, infection, endograft failure, and endograft migration. Open surgical repair is now reserved for patients with unfavorable anatomy for endovascular therapies. This review provides a comprehensive overview of ATAI including its epidemiology and demographics, mechanisms of injury, clinical and radiographic diagnosis, treatment options, and posttherapeutic follow-up.

Extracorporeal membrane oxygenation (ECMO) has proven to be an invaluable method of cardiopulmonary support in cases of severe cardiogenic shock. In an emergency, femoral artery and vein cannulation is the easiest and quickest access to initiate support. Often, with peripheral venous-arterial ECMO (VA ECMO), an inadequate reduction in left ventricular end-diastolic pressure (LVEDP) is present secondary to increased afterload from retrograde flow, inadequate RV drainage or persistent bronchial circulation. Elevated LVEDP has been known to be associated with poor myocardial recovery, LV thrombus formation and significant pulmonary edema. A cannulation strategy to achieve partial ventricular unloading is of paramount importance when considering ECMO support following cardiogenic shock to increase the potential for myocardial recovery. We present a novel case of emergent peripheral VA ECMO cannulation with a trans-diaphragmatic left ventricular (LV) vent in a 61-year-old, 79 kg male with end-stage liver disease and hepatitis B cirrhosis who suffered cardiac arrest during orthotopic liver transplantation.

We present two cases of Amplatzer® device deployment that exhibited long-term failure necessitating surgical correction. The first case illustrates recanalization of a ruptured Valsalva aneurysm with worsening aortic insufficiency after percutaneous repair with the Amplatzer Vascular Plugs and Amplatzer duct occluder, while the second case illustrates recanalization after deployment of the Amplatzer septal occluder in a patient with a pseudoaneursym in a bovine aorta after type I aortic dissection repair. These two cases illustrate the potential long-term complications and limitations in durability with these devices.