Introduction: Now a days the vast expansion to ECMO indications raises ethical questions such as whose patient should be treated with ECMO and when the ECMO support should be discontinued?
Case presentation: 57yr old gentleman presented as ACS and 1yr PCI was planned. CAG revealed total occlusion of LAD; LCX: mild lesions, RCA: totally occluded. Attempt to open the RCA was failed, LAD was stented but after that he got CP arrest. CPR was initiated and continued for 1.5h, then he revived, but echocardiography showed EF 10%.
VA-ECMO was inserted then shifted to CCU and started to be awake. CXR showed massive left pleural effusion so exploratory thoracotomy was done which revealed big blood collection from intercostal artery and fracture multiple ribs.
In 3rd day he was taken to the CathLab electively for another trial to open the RCA which was successfully done. ECMO was weaned off successfully in 5th day post implantation. Echocardiography showed EF 40%.
Then he got aggressive chest infection and septicemia. Hemodynamic deterioration increased so we re-implanted VA- ECMO again after 48h from explantation for 2nd time and he again started to improve.
In 3rd week he got massive hematemesis, melena and upper GIT endoscopy revealed massive erosive gastritis. In 30th day post cardiac arrest the oxygenator of the ECMO started to be clotted so ECMO was explanted and he deteriorated and death was declared in next day.
Conclusion: Earlier and rapid decision for ECMO is better and the question for starting ECMO in cardiogenic-shock before PCI needs to be raised and validated. Bleeding is the major risk of ECMO due to continuous infusion of heparin to protect ECMO circuit.
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