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An otherwise healthy 22-year-old male presented with signs and symptoms suggestive of acute appendicitis. His clinical status rapidly deteriorated, requiring mechanical ventilation and vasopressor support. Cardiothoracic surgery was consulted for initiation of extra-corporeal membrane oxygenenation (ECMO) in the setting of intractable septic shock.
Bedside echocardiogram revealed a sinus of Valsalva aneurysm rupture. Emergency surgical repair was performed. The aorta was divided and the aortic valve was inspected. The right atrium was opened parallel to the AV groove. The classic “windsock” deformity of a sinus of Valsalva aneurysm was identified through the septal leaflet of the tricuspid valve. The aneurysmal tissue was resected and the defect was repaired with a CardioCel patch and secured in place with fine 5-0 Peters sutures. The edge of the anterior leaflet of the tricuspid valve was brought over the defect of the septal leaflet and reinforced with a small piece of CardioCel patch. Postoperative TEE showed no aortic insufficiency, and minor tricuspid regurgitation.
The patient had an uneventful recovery and was discharged home on postoperative day four. Initiation of ECMO support would have been detrimental to this patient’s outcome due to unrestricted pulmonary blood flow and worsening cardiogenic shock, which would likely have resulted in multi-organ system failure and death.
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2 Comments
This is a nice case report.
However what it really shows is not just that ECMO is not always the solution, but that proper clinical assessment, judgement and decision making remains very important. Every therapy has its place and on other occasions may be clearly inappropriate.
The patient had a soft abdomen so that the working diagnosis of appendicitis was very unlikely.
He had a wide pulse pressure, a murmur and lung crepitations. The latter two signs would clearly be abnormal in a young patient. I bet that he had a collapsing pulse due to the huge aortic run-off.
As a cardiac surgeon, one often gets the urgent call to see a patient for ECMO. In at least half of the cases the situation can be managed without ECMO or it is clearly not appropriate (such as a cardiac arrest with already a long downtime, endocarditis with significant AR which needs surgery like this case, etc)
Thank you Andrew, I completely agree with you