Reversal of Acute Right Ventricular Failure Early Post Left Ventricular Assist Device Placement by Intratracheal Milrinone Administration Case Report Ying Tung Sia, MD; Caroline E. Gebhard, MD; and André Y. Denault, MD, PhD CHEST 2021; 159(1):e57-e60 A 58-year-old man with medical history of hypertension and pulmonary sarcoidosis presented with palpitation and syncope. At arrival in the ED, multiple episodes of nonsustained ventricular tachycardia have been recorded. Transthoracic echocardiography (TTE) showed severe left ventricular dysfunction with suspected cardiac sarcoidosis. Shortly after admission, the patient went into cardiac arrest due to refractory ventricular tachycardia. CPR was performed, and venous-arterial extracorporeal membrane oxygenation was inserted through a femoral approach without complication. After 10 days of extracorporeal membrane oxygenation support, despite high doses of steroids and immunosuppressive therapy with cyclophosphamide, electrical myocardial irritability persisted with recurrent episodes of ventricular tachycardia that required external defibrillation. A TTE was performed and showed persistent severe left ventricular dysfunction and normal right ventricular function. The patient was assigned for left ventricular assist device (LVAD) placement set at 9000 rounds per minute that resulted in optimal cardiac output and stable hemodynamics with normal pulmonary artery pressure. Shortly after LVAD implantation, the patient had signs of profound cardiogenic shock with severe hypotension. High-dose vasoactive support with epinephrine and norepinephrine was started. An LVAD low pump flow alarm was engaged, and a suction event was suspected. Bedside transesophageal echocardiography (TEE) was performed (Video 1). Despite decreasing the pump speed from 9000 to 8000 rounds per minute, the patient’s condition remained unstable (Video 2). A bolus of milrinone (2.5 mg) was administered directly into the endotracheal tube with a syringe under continuous TEE monitoring. Shortly after the instillation, hemodynamics rapidly improved, and the LVAD suction event alarm stopped (Video 3). The instillation of 2.5-mg milrinone was repeated, and the patient’s hemodynamics were restored completely after 10 minutes (Video 4)(Fig 1). Continuous TEE monitoring showed improved right ventricle load and contractility, optimized left ventricular filling and function, and restoration of the ventricular interdependence (Video 3). AFFILIATIONS: From the Department of Medicine, Service of Cardi- ology and Critical Care, CIUSSS-MCQ (Dr Sia), Trois-Rivières, QC, Canada; the Department of Intensive Care Medicine (Dr Gebhard), University Hospital Basel, Basel, Switzerland; and the Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal (Dr Denault), Montreal, QC, Canada. FUNDING/SUPPORT: C. E. G. was supported by grants from the Research Foundation in Anesthesiology and Intensive Care Medicine, University Hospital Basel, the Research Fund of the University of Basel. A. Y. D. was supported by the Montreal Heart Institute Foundation and the Richard I. Kaufman Endowment Fund in Anesthesia and Critical Care. CORRESPONDENCE TO: André Y. Denault, MD, PhD, Montreal Heart Institute, 5000 Belanger St, Montreal, QC, Canada, H1T 1C8; e-mail: [email protected] Copyright Ó 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved. DOI: https://doi.org/10.1016/j.chest.2020.01.059 [ Ultrasound Corner ] chestjournal.org e57
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Related Documents
