| Abstract [eng] |
Background: Paravalvular leaks are a recognized complication of valve replacement surgery, particularly challenging in high-risk patients with severe pulmonary hypertension. Transapical closure provides a less invasive alternative to reoperation but carries significant risks including myocardial perforation and catastrophic bleeding. In such emergencies, extracorporeal membrane oxygenation can provide critical circulatory support and myocardial unloading. Case Presentation: A 75-year-old woman with prior mitral and aortic valve replacement, atrial fibrillation, diabetes, and pulmonary embolism presented with severe mitral regurgitation from five mitral paravalvular leaks. Echocardiography showed preserved left ventricular function, right ventricular dilation, and pulmonary artery pressure of 100 mmHg. During transapical closure, the right ventricle was accidentally accessed, causing rupture and massive bleeding. Peripheral venoarterial extracorporeal membrane oxygenation was initiated. A Foley catheter was used for tamponade, followed by pledget-reinforced U-sutures. Four leaks were closed the next day, reducing regurgitation to mild. Extracorporeal support was discontinued within 24 hours. The patient developed acute renal failure requiring renal replacement therapy and was discharged to rehabilitation on postoperative day 40. Objective: This thesis aims to evaluate the role of ECMO in managing severe intraoperative complications during high-risk mitral PVL interventions, particularly in cases of myocardial rupture, severe pulmonary hypertension, and hemodynamic collapse. Through the case study of a 75-year-old patient who experienced unintended right ventricular rupture during transapical PVL closure, we highlight the challenges of PVL repair in high-risk patients and the role of ECMO in preventing catastrophic cardiovascular collapse. In parallel, through a comprehensive literature review, we analyze existing evidence on ECMO’s application in PVL management, myocardial rupture repair, and intraoperative bleeding control. This review is to contextualize the findings of our case study within current clinical trends and to identify gaps in knowledge regarding ECMO utilization in elderly cardiac surgery patients. Methods: A systematic literature review was conducted to assess ECMO utilization in high-risk cardiac procedures, including PVL management, myocardial rupture, and intraoperative bleeding control. Studies evaluating prophylactic versus emergency ECMO use were reviewed to determine optimal management strategies for ECMO deployment. Results: This case underscores ECMO’s role as a vital hemodynamic support strategy in cases of myocardial rupture and severe intraoperative bleeding. Literature findings confirm ECMO’s potential to improve procedural success rates and perioperative survival in high-risk cardiac interventions, though it presents risks such as coagulopathy, thromboembolic events, renal dysfunction, and vascular complications. Evidence suggests that prophylactic ECMO use may lead to improved outcomes compared to emergency ECMO initiation. Moreover, this case highlights the effectiveness of novel hemostatic strategies such as the Foley catheter tamponade technique in managing acute myocardial rupture. Conclusion: ECMO remains a vital adjunct in high-risk cardiac procedures, particularly in cases where myocardial rupture and hemodynamic instability pose extensive threats to patient survival. This case emphasizes the importance of early ECMO deployment, novel hemostatic interventions, and a staged approach to PVL management in structurally complex valvular procedures. While ECMO provides perioperative support, long-term data on its use in PVL repair remains limited, emphasizing the importance of continued research into selection criteria, weaning strategies, and geriatric outcomes. |
