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SAGE Open Med Case RepSAGE Open Med Case RepSCOspscoSAGE Open Medical Case Reports2050-313XSAGE Publications Sage UK: London, England 10.1177/2050313X1878921710.1177_2050313X18789217Case ReportShould heart failure patients be left to fate? Temporary
implementation of veno-arterial extracorporeal membrane oxygenation for
haemodynamic support during excision of rectal carcinoma in an end-stage
biventricular heart failure patient Hergesell Vera 1https://orcid.org/0000-0002-8883-3183Mathew Erwin 2Kornprat Peter 2Knez Igor 1Mischinger Hans-Joerg 2Dapunt Otto 1Spiliopoulos Sotirios 11 Division of Cardiac Surgery, Department
of Surgery, Medical University of Graz, Graz, Austria2 Division of General Surgery, Department
of Surgery, Medical University of Graz, Graz, AustriaPeter Kornprat, Department of General
Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria.
Email: peter.kornprat@medunigraz.at30 7 2018 2018 6 2050313X1878921723 4 2018 18 6 2018 © The Author(s) 20182018SAGE PublicationsThis article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which
permits non-commercial use, reproduction and distribution of the work
without further permission provided the original work is attributed as
specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).Management of end-stage heart failure patients requiring major general surgery is
not well defined. Due to poor cardiorespiratory reserve, perioperative morbidity
and mortality are excessively high. We report a case of temporary implementation
of veno-arterial extracorporeal membrane oxygenation for haemodynamic support
during excision of rectal carcinoma in an end-stage heart failure patient and
describe perioperative management.

Heart failurecarcinomamechanical circulatory supportcover-dateJanuary-December 2018
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Introduction
End-stage heart failure patients requiring major general surgery are at high risk for
perioperative morbidity and mortality.1 Poor cardiorespiratory reserve and volume shift predispose patients to severe
haemodynamic instability and potentially fatal acute heart failure. We describe a
case of successful temporary implementation of veno-arterial extracorporeal membrane
oxygenation (ECMO) for haemodynamic support during excision of rectal carcinoma in
an end-stage biventricular heart failure patient, including perioperative
management. Written informed consent to publish this report was obtained from the
patient.

Case report
A 63-year-old male Caucasian with end-stage heart failure due to ischaemic
cardiomyopathy and a history of recurrent cardiac decompensation despite optimal
medical therapy according to the guidelines of the European Society of Cardiology
for treatment of chronic heart failure2 was admitted for surgical treatment of a rectal adenocarcinoma. A colonoscopy
performed due to haematochezia during hospitalization revealed an apparently
malignant tumour at 8 cm from the sphincter. Histological examination of the
specimen showed an invasive, ulcerated, poorly differentiated transmural
adenocarcinoma.

Echocardiographic examination revealed dilation (left ventricular end-diastolic
diameter: 47 mm, right ventricular longitudinal diameter: 85 mm, mid-right
ventricular diameter: 85 mm) and severe systolic dysfunction of both ventricles
(left ventricle: ejection fraction 15%, global longitudinal strain: –3.9%/right
ventricle: tricuspid annular plane systolic excursion: 8 mm). Right heart
catheterization documented severe pulmonary hypertension (mean pulmonary artery
pressure: 54 mmHg) and compromised cardiac output (cardiac index: 1.8 L/min/m²).
Functional state at admission was reduced (New York Heart Association (NYHA) stage
IIIb). Exercise capacity was severely restricted with the patient requiring
assistance during routine activities. The patient and his relatives were informed of
the necessity to implement temporary mechanical circulatory support during excision
of the rectal carcinoma and possibly total artificial heart therapy as destination
therapy should weaning from veno-arterial ECMO support fail.

Levosimendan preconditioning (0.1 μg/kg/min) was performed 24 h prior to surgery to
increase right ventricular contractility and decrease cardiac afterload.
Intraoperatively, following introduction of the arterial cannula over a 10-mm Dacron
graft in the axillary artery, percutaneous venous cannulation of the right jugular
vein and a single administration of 50 U/kg unfractioned heparin, partial ECMO
support (Bio Console 560; Medtronic Minnesota, USA) was initiated with pump flow of
1.5 L/m2/min. Mesorectal excision of the carcinoma and temporary
ileostomy were then performed in a state of full haemodynamic stability. Histologic
examination showed an invasive, ulcerated, poorly differentiated transmural
adenocarcinoma with locoregional lymph-node metastases (tumour classification: G3
pT3 N2a(6/14) R0 L1).

In order to prevent bleeding complications, we did not administer continuous systemic
anticoagulation with intravenous heparin during ECMO therapy. The patient was
successfully weaned from ECMO support 22 h later and from mechanical ventilation on
postoperative day 2. He was discharged from hospital on postoperative day 13 and has
to date, 55 days after surgery, experienced no adverse events. The tumour board
rejected adjuvant chemotherapy on the basis of the patient’s cardiac state.
End-stage heart failure (NYHA IIIb) still limits the patient’s quality of life.
Ileostomy closure is planned after general recovery without ECMO, depending on the
cardiac state.

Discussion
Management of end-stage heart failure patients during major general surgery poses a
significant challenge to treating physicians and is still not well defined. During
preoperative preparation, special care should be taken to optimize cardiac function.
We preconditioned our patient with levosimendan, a calcium sensitizer with positive
inotropic as well as vasodilatory effects in the systemic and pulmonary circulation,
which improved cardiac output and decreased mean pulmonary artery and atrial pressure.3 Due to the long half-life of its active circulating metabolite OR-1896, a
single preoperative infusion of levosimendan is still effective during the
prognostically crucial early postoperative course.3 In the intra- and postoperative setting, the focus must be on anticipating
technical or surgical complications that could potentially compromise cardiac
function and therefore impede weaning from ECMO support. Cannulation of the axillary
artery and the jugular vein facilitates any positioning of the patient that is
necessary to optimally expose the surgical site without the risk of cannula kinking.
The use of heparin-coated circuits and centrifugal pumps allows delayed initiation
and as in our case even short-term withdrawal of systemic anticoagulation.4 The implementation of only partial ECMO support in combination with the
lasting effects of preoperative levosimendan therapy proved to be helpful in
maintaining a high degree of pulsatility and facilitating early weaning in a patient
who according to current criteria has no myocardial recovery potential.5

Conclusion
This case demonstrates that safe performance of major general surgery in end-stage
heart failure patients is feasible, provided that special care is taken to optimize
cardiac function before surgery and to avoid technical complications in the
operative setting. Perioperative application of a calcium sensitizer stabilizes
cardiac function and due to its long half-life facilitates early weaning from
temporary mechanical circulatory support. Intraoperative cannulation of the axillary
artery and the jugular vein facilitates proper positioning of the patient without
the risk of cannula kinking.

This case report was initiated and supported equally by the Division of General
Surgery and the Division of Cardiac Surgery, Department of Surgery, Medical
University of Graz. The authors of this manuscript state that this work received no
funding. The authors thank Dr Andreas Grün for assisting the operative procedure.
E.M. and V.H. contributed equally.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the
research, authorship, and/or publication of this article.

Ethical approval: Our institution does not require ethical approval for reporting individual cases
or case series.

Funding: The author(s) received no financial support for the research, authorship, and/or
publication of this article.

Informed consent: Written informed consent was obtained from the patient(s) for their anonymized
information to be published in this article.

ORCID iD: Erwin Mathew 
https://orcid.org/0000-0002-8883-3183
==== Refs
References
1 
Fleisher LA Fleischmann KE Auerbach AD et al 
2014 ACC/AHA guideline on perioperative
cardiovascular evaluation and management of patients undergoing noncardiac
surgery: executive summary: a report of the American College of
Cardiology/American Heart Association Task Force on Practice
Guidelines . Circulation 
2014 ; 130 :
2215 –2245 .25085962 
2 
Ponikowski P Voors AA Anker SD et al 
2016 ESC guidelines for the diagnosis and
treatment of acute and chronic heart failure: the task force for the
diagnosis and treatment of acute and chronic heart failure of the European
Society of Cardiology (ESC) developed with the special contribution of the
Heart Failure Association (HFA) of the ESC . Eur
Heart J 
2016 ; 37 (27 ):
2129 –2200 .27206819 
3 
Toller W Heringlake M Guarracino F et al 
Preoperative and perioperative use of
levosimendan in cardiac surgery: European expert opinion .
Int J Cardiol 
2015 ; 184 :
323 –336 .25734940 
4 
Bonacchi M Spina R Torracchi L et al 
Extracorporeal life support in patients with
severe trauma: an advanced treatment strategy for refractory clinical
settings . J Thorac Cardiovasc Surg 
2013 ; 145 (6 ):
1617 –1626 .22982033 
5 
Aissaoui N El-Banayosy A Combes A.  
How to wean a patient from veno-arterial extracorporeal membrane
oxygenation . Intensive Care Med 
2015 ; 41 (5 ):
902 –905 .25619488