Triple ECMO Therapy and Emergency PCI Performed Perioperatively During Pediatric Heart Transplantation

Title Triple ECMO Therapy and Emergency PCI performed perioperatively during Pediatric Heart Transplantation Introduction Post-heart transplant patients may at times present with ventricular dysfunction which may be secondary to graft rejection, donor coronary artery disease or cardiac allograft vasculopathy. In this case report, we will be describing about a young boy with dilated cardiomyopathy and severe biventricular dysfunction who deteriorated post-heart transplantation and how he was revived. Clinical Case 8 years boy, known case of dilated cardiomyopathy with severe biventricular dysfunction awaiting heart transplantation sustained cardiac arrest. He was initiated on central Extracorporeal Membrane Oxygenation (ECMO) as bridge to heart transplantation and stabilised. After 3 weeks of waiting period he underwent heart transplantation. In the immediate post transplant period, he developed severe hypotension and severe LV dysfunction and so emergency peripheral veno-arterial ECMO was initiated. Gradually his LV function improved, ECMO was removed and shifted to ward. In the ward, child developed easy fatigability and generalized weakness. Echocardiography showed good LV function, dilated RV and free TR with non-coapting tricuspid valve. He was shifted back to ICU. He had sudden onset of VF and so he was defibrillated; CPR was started, he was reintubated. His ECG showed ischemic changes. He was immediately shifted to cath lab for coronary angiography and endomyocardial biopsy. Graft rejection was suspected and pulse steroid was administered. Coronary angiography was technically challenging in this patient and it revealed donor transmitted triple vessel coronary artery disease with intermediate left main disease. In view of critical lesion with thrombus in RCA and LAD, ad hoc PTCA, again a technically demanding procedure, was performed for these two vessels. Endomyocardial biopsy performed showed no rejection of graft. Meanwhile, patient hemodynamically deteriorated due to acute stent thrombus of RCA. CPR was restarted and RCA was revascularized again. Peripheral veno-arterial ECMO was established again for the third time in this patient; this time in cath lab. Final angiography showed good flow in LAD and RCA. Gradually the patient recovered well and discharged with good biventricular function. Discussion Noticeably, for the first time in the world, ECMO was performed thrice in this patient and successfully revived. Emergency coronary stenting for donor transmitted coronary artery disease was performed in pediatric patient with technical challenges.