Suicide right ventricle after lung transplantation for pulmonary vascular disease

Abstract

A 27-year-old female with Eisenmenger's syndrome underwent closure of a patent ductus arteriosus, closure of a perimembranous ventricular septal defect and mid muscular defect and bilateral lung transplantation. Her immediate postoperative course was complicated by severe right ventricular outflow tract (RVOT) obstruction resulting in hemodynamic collapse, a condition described as suicide right ventricle. The patient was placed on central Veno-Arterial Extra-Corporeal Membrane Oxygenation as a bridge to the relief of RVOT obstruction which included a right ventricular outflow muscle resection and a right ventricle outflow tract patch. The patient made an uneventful recovery.

Right Ventricular Outflow Tract Obstruction in Adults: A Systematic Review and Meta-analysis

“… 223 Most of the other reported cases were observed after lung transplantation (n = 9). 55 , 61 , 65 , 67 , 70 , 108 , 142 , 231 Two cases occurred as a result of cardiac surgery complications, 134 , 242 and one case resulted from a postoperative mediastinal hematoma. 66 A single case could be attributed to cardiac catheterization, which iatrogenically precipitated infundibular muscular spasm in a patient with pulmonic stenosis and thus dynamic RVOTO.…”

“…In patients receiving inotropes, the term “suicide RV” has been used to describe the acute onset of dynamic RVOTO. 10 , 67 , 231 Kirshbom et al provided a very convincing hypothesis explaining this phenomenon. 70 Pulmonary allograft candidates often suffer from chronic pulmonary hypertension, leading to structural changes in the heart.…”

Right Ventricular Outflow Tract Obstruction in the Intensive Care Unit: A Case Report of 2 Patients

“…These include changes in volume status and use of inotropic agents, 4 , 9 particularly in the context of hypertrophic cardiomyopathy. 13 Dynamic RVOTO may also occur after lung transplantation 3 and pulmonic stenosis correction. 8 The term “suicide” RV has been used to describe dynamic RVOTO occurring after acute reduction of RV afterload, such as after lung transplantation or due to RVOT spasm during catheterization.…”

“…Severe RVOTO has been reported after lung transplantation, cardiac surgery, and cardiac catheterization, and has been called “suicide” RVOTO 1 , 3 , 7 as a result of acute reduction in RV afterload. 4 , 8 We describe the first cases of RVOTO diagnosed postoperatively in the ICU using continuous Prv waveform monitoring.…”

Management of Eisenmenger syndrome by cardiac defect closure combined bilateral lung transplantation with intraoperative venoarterial ECMO support

“…Secondly, the implantation of ECMO significantly shortened the period for cardiac arrest and full systemic anticoagulation, this could reduce the risk of bleeding and affecting cardiac function 3 . Furthermore, the ECMO can provide continuous cardiopulmonary assistance after the surgery, thus allowing the hypertrophic heart to better adapted to the dramatically changing PAP, otherwise a devastating dynamic right ventricular outflow obstruction would likely occur 4 . Finally, VA‐ECMO could avoid uncontrolled reperfusion to the graft, lowering the risk for primary graft dysfunction 5 .…”