Successful management by employing situational extracorporeal membrane oxygenation strategies in a patient with acute type A aortic dissection: a case report

BackgroundWe successfully treated a case of acute type A aortic dissection in a patient with acute inferior wall infarction as well as severe circulatory and respiratory disorders.Case presentationA 69-year-old woman was diagnosed with acute type A aortic dissection. She received emergency partial aortic arch replacement and coronary artery bypass grafting. After the cardiopulmonary bypass, extracorporeal membrane oxygenation (ECMO) with central cannulation was performed due to severe right heart failure and extensive alveolar hemorrhage. Since the surgery, transesophageal echocardiography was used to monitor her hemodynamic status. The positive end-expiratory pressure (PEEP) was managed based on end-expiratory transpulmonary pressure. Replacement of the ECMO circuit was required every 2-3 days due to intra-circuit thrombus, and continuous renal replacement therapy was started on postoperative day (POD) 8. On POD 13, improvement of cardiac function was observed; we therefore attempted closure of the chest and conversion to veno-venous (V-V) ECMO. However, the patient's hemodynamics were unstable due to diastolic impairment after the chest closure; thus, peripheral veno-arteriovenous (V-AV) ECMO was introduced. The patient was converted to V-V ECMO on POD 16 and weaned from ECMO on POD 17. The patient was extubated on POD 19. She left the intensive care unit with non-invasive ventilation on POD 20.ConclusionsThe favorable outcome in the current case can be attributed to the following three points: (1) appropriate ECMO strategies were employed according to the patient's condition, (2) the patient's lung condition improved due to transpulmonary pressure monitoring and fluid balance management from an early stage, and (3) we observed respiratory and hemodynamic status during the 50-90-s circulatory arrest periods that occurred during ECMO circuit changes, and this observation contributed to the evaluation of weaning from ECMO.