Extracorporeal membrane oxygenation as a "bridge to recovery" in a case of myotomy for myocardial bridge complicated by biventricular dysfunction

The incidence of cardiac dysfunction after routine cardiac surgical procedures is quite high (3-5%), but the majority of patients improve using inotropic drugs or intraaortic ballon counterpulsation. However, approximately 1% of these patients do not benefit from using these supports, and they need more invasive strategies, such as ventricular assist devices. Extracorporeal membrane oxygenation (ECMO) is one of them, and it offers biventricular support, can be managed very easily and is one of the cheapest devices. We describe our experience with ECMO in a case of postocardiotomy failure after myotomy for myocardial bridge. Because of failure of medical therapy, we decided to perform surgical myotomy of the bridge and coronary artery bypass grafting of the LAD with the left internal mammary artery. Many episodes of ventricular fibrillation occurred with quick worsening of biventricular function requiring extracorporeal membrane oxygenation (ECMO) support. The pump flow was maintained at about 1.8-2 l/m(2) (about 80% of the ideal flow) in order to reduce cardiac work offering a more rapid recovery of cardiac function. ECMO support was slowly reduced because EKG progressively improved and the hemodynamic parameters were stable. ECMO was interrupted in the 4th postoperative day when mean pressure was > 90 mmHg and organ perfusion was adequate. The particularity of our case was the complicated management of MB: it is very uncommon that myotomy of the LAD results in biventricular dysfunction. Our experience confirms that benign pathologies such as MB may hide life-threatening complications and that ECMO support is the simplest solution in case of biventricular dysfunction.