ECMO and POPH: More Help for the Right Heart

Abstract

The decision to offer liver transplantation (LT) in the presence of POPH is dependent upon improving pulmonary hemodynamics from baseline, as determined by right heart catheterization, and trying to optimize function of the right ventricle (RV) prior to surgery. Outcomes remain unpredictable 1. Despite attaining these goals with the current buffet of pulmonary artery (PA) targeted therapies, the risks of LT remain significant. Hepatectomy may be complicated by severe bleeding with the transfusion of blood products stressing an already impaired right ventricle. Reperfusion of the

Veno-Arterial Extracorporeal Membrane Oxygenation Rescue in a Patient With Pulmonary Hypertension Presenting for Revision Total Hip Arthroplasty: A Case Report and Narrative Review

“…In patients with PH who deteriorate into cardiopulmonary arrest, resuscitation is often difficult and have had limited success [25,84,87]. The use of VA-ECMO as a rescue in cardiopulmonary arrest has been increasing in the United States, as there has been increased availability of membranes and portable circuits, the ability of ECMO to provide left, right, and biventricular support, its ease of implantation intraoperatively, in the catheterization laboratory, or even bedside [7,8,88]. VA-ECMO insertion during cardiopulmonary arrest has revamped its role in initial cardiopulmonary resuscitation (CPR) management [89,90].…”

“…While the use of VA-ECMO can be used as rescue therapy during a pulmonary hypertensive crisis and/or cardiopulmonary resuscitation, we should be mindful of the final goals of therapy. ECMO does not support RV directly, it has been used as a temporizing measure to provide circulatory support in an ICU setting while the myocardium has time to recover or as a bridge to a decision therapy to achieve stability for end-organ perfusion until more definitive mechanical support therapy or cardiac replacement therapy can be instituted [7,8,88]. However, these patients who are placed on ECMO and do not proceed to transplantation often remain at a high mortality risk [25,83].…”

“…We report a case of a 57-year-old patient with severe PH who underwent a revision total hip arthroplasty under combined spinal-epidural (CSE) anesthesia. Emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was placed as a rescue therapy during pulmonary hypertensive crisis and served as a temporary support [7,8]. We present a narrative review on perioperative management for patients with PH undergoing non-cardiac surgery.…”