ECMO for Large Anterior Mediastinal Mass
Francis Hartge, Naval Medical Center San Diego, Coronado, CA
Francis Hartge1, Arvin Narula, M.D.2, Luke Oakley, M.D., FSCAI3, Raghava Gollapudi, MD4, Christian Matabang2, Justin Michael Cox, M.D.2 and Ryan Schmitt, PA-C3, (1)Naval Medical Center San Diego, Coronado, CA, (2)San Diego Cardiac Center, San Diego, CA, (3)Naval Medical Center San Diego, San Diego, CA, (4)San Diego Cardiac Center, san diego, CA
Title
ECMO for Large Anterior Mediastinal Mass
Introduction
Mediastinal masses can compress critical structures in the chest due to their location and insidious growth. Due to their intrinsic wall tension the superior vena cava (SVC), pulmonary arteries (PA), and trachea are compressed in that order. When this occurs, patients may need cardiopulmonary support while awaiting definitive diagnosis and treatment. Traditionally, extracorporeal membrane oxygenation (ECMO) is used for refractory cardiogenic shock or respiratory failure. Here we present a case of a large anterior mediastinal mass (AMM) resulting in critical airway compromise, SVC syndrome, and compression of the PA who was supported with ECMO.
Clinical Case
A 50-year-old male presented with dysphagia, dysphonia, dyspnea on exertion, and a fifteen-pound unintentional weight loss over six weeks. A chest x-ray revealed a large AMM. He was hypoxic and had dilated anterior chest wall veins. A chest CT scan with contrast revealed a large AMM causing severe narrowing of the trachea and the proximal mainstem bronchi, occlusion of the SVC, and compression of the right main PA. Echocardiogram showed a severely compressed left atrium. Tracheal compression precluded endotracheal intubation, so the decision was made to place him on VA-ECMO. The patient was unable to lie flat so vascular access was obtained while the patient was in a semi-upright position using braided sheaths in the right common femoral artery (CFA) and left common femoral vein (CFV). He was then sedated, and access was escalated to 19Fr arterial cannula and 25Fr venous cannula. He then underwent biopsy of the mass and palliative radiation. On hospital day #2 VVA ECMO was started due to persistent hypoxemia and Harlequin syndrome. On HD #3 he underwent successful fiberoptic bronchoscopy with endotracheal intubation, removal of his femoral arterial catheter, and was maintained on VV ECMO. Three days later he was fully decannulated from ECMO and was extubated shortly thereafter. The biopsy revealed a diagnosis of T-cell lymphoma. He was discharged on hospital day #17 with plans to continue chemotherapy treatment as an outpatient.
Discussion
ECMO can be a lifesaving intervention for patients with large AMM. When these patients are deeply sedated the weight of the mass can cause further compression of the great vessels. The decision to place this patient on VA ECMO was driven by two factors. He had compression of his PA and left atrium and there was concern for cardiovascular collapse. Additionally, femoral veins are the only venous access options in patients with SVC syndrome. For both reasons, we opted for VA strategy up front rather than VV. This patient was also in significant respiratory distress at presentation, so awake and upright vascular access allowed for rapid repositioning and cannulation after sedation was administered. Our case highlights the safety and utility of ECMO for patients with large AMM with airway compromise as well as unique considerations for patients with SVC syndrome.