Successful treatment of large left ventricular thrombosis during
extracorporeal membrane oxygenation (ECMO):a case report and review of
the literature
Xue-ting Yang, MM1**, Yi-jin Chen,
MM1,2,3**, Han Zeng, MM1**, Lei
Deng, MM1, Li Chang, MM1, Yi Li,
MM1, Meng-long Song, MM1, Yang
Zhang, MM1, Wei Peng, MM1,
Dong-Wang, MM1,2,3, Hong-qiong Peng,
MM1+, Hua Jiang, MD1,2+
1 Emergency intensive care unit, Sichuan Provincial People’s
Hospital, University of Electronic Science and Technology of China, No.
32, West Second Section, 1st Ring Road, Chengdu 610072, Sichuan,
China; 2 Institute for Emergency and Disaster Medicine, Sichuan
Academy of Medical Science, Sichuan Provincial People’s Hospital, School
of Medicine, University of Electronic Science and Technology of China, No. 32, West Second Section, 1st Ring Road, Chengdu610072, Sichuan, China; 3 University of Electronic Science and Technology
of China, Chengdu 6100054, China.
+Corresponding Author: Hong-qiong Peng, Emergency intensive
care unite, Sichuan Provincial People’s Hospital, University of
Electronic Science and Technology of China, No. 32, West Second Section,
1st Ring Road, Chengdu 610072, Sichuan, China. Tel: +86-28-87393496,
Email: 2294398778@qq.com. Hua Jiang, Emergency intensive care unite,
Sichuan Provincial People’s Hospital, University of Electronic Science
and Technology of China, No. 32, West Second Section, 1st Ring Road,
Chengdu 610072, Sichuan, China. Tel: +86-28-87393881, Email:
jianghua@uestc.edu.cn.
**These authors have contributed equally to this work
Author Contributions:
Xue-ting Yang: Writing-original draft.
Yi-jin Chen: Writing-original draft.
Han Zeng: Writing-original draft.
Lei Deng: Acquisition, analysis, or interpretation of data.
Li Chang: Acquisition, analysis, or interpretation of data.
Yi Li: Acquisition, analysis, or interpretation of data.
Meng-long Song: Acquisition, analysis, or interpretation of data.
Yang Zhang: Acquisition, analysis, or interpretation of data.
Wei Peng: Acquisition, analysis, or interpretation of data.
Dong-Wang: Writing-review and editing.
Hong-qiong Peng: Supervision.
Hua Jiang: Writing-review and editing, supervision and obtained funding.
Funding
This work was supported by funding from the Sichuan Science and
Technology Program (Grant ID: 2021YFS0378) to Hua Jiang.
Conflict of interest statement
All authors have nothing to declare.
Data availability statement
The corresponding author’s data supporting this study’s findings are
available upon reasonable request.
Consent
Written informed consent was obtained from the patient to publish this
report in accordance with the journal’s patient consent policy.
ORCID
Yi-jin Chen https://orcid.org/0009-0009-8075-1093
Key clinical message
We report the case that a fulminant myocarditis patient was treated with
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) and
experienced a rare complication of left ventricular giant thrombosis.
After anticoagulation alone without surgical intervention, the
thrombosis disappeared. This case illustrates anticoagulant alone
therapy is safe and effective on treatment of giant left ventricular
thrombosis during ECMO.
Keywords: extracorporeal membrane oxygenation (ECMO), left ventricular
(LV) thrombosis, anticoagulant.
Introduction
Extracorporeal membrane oxygenation (ECMO) is widely used to patients
with fulminant myocarditis, severe heart failure or respiratory failure
or combined cardiorespiratory failure. It has been more than 50 years
since ECMO was first successfully used to save the patient’s life.
According to the return cycle, ECMO is classified by venoarterial
extracorporeal membrane oxygenation (VA-ECMO) and venovenous
extracorporeal membrane oxygenation (VV-ECMO). ECMO is a high-risk
operation technique, which may cause fatal complications, such as
massive bleeding, thrombosis and infection. This article hereby reported
one case that left ventricular (LV) thrombosis occurred during ECMO and
was successfully treated with anticoagulant alone without surgery.
Case presentation
A 28-year-old male (height 174cm, weighing 55kg) was admitted to the
Emergency Intensive Care Unit (EICU) of our hospital on March 15, 2023
due to recurrent fever for 5 days. Electrocardiogram revealed V4-V6 ST
segment elevation 0.05-0.2mv(Fig.1 panel A ) and hyper-sensitive
troponin T(hs-cTnT)was 5135ng/L. Six hours after admission,
ventricular fibrillation occurred suddenly. Electric defibrillation was
immediately applied, and chest compression was continued. He was
diagnosed with fulminant myocarditis and cardiogenic shock and was
connected to VA-ECMO immediately. The initial speed was 9200/min, the
blood flow was 3.6L/min, the norepinephrine was 1.5ug/(kg/min) and
heparin anticoagulation was 1u/(kg/h). Activated clotting time
[ACT] was monitored every 4 hours, activated partial thromboplastin
time [APTT], prothrombin time [PT], and anti-Xa were monitored
four times a day. On March 17, 2023, echocardiography showed that
thrombosis in the patient’s left ventricular (LV) (33*23mm in width,
Fig.1 panel B, arrow). On March 20, 2023, the maximum diameter of the
thrombosis was 47*12mm (Fig.1 panel C, arrow) and left ventricular
ejection fraction (LVEF) (biplane Simpson method) was 54%.
Treatment
Because of poor cardiac function, the surgical procedure is not
available. Thus, we strengthen anticoagulation treatment. Anticoagulant
targets were adjusted to ACT>180s and APTT>60.
Because of the high activity of antithrombin III, heparin
anticoagulation was adjusted to 18u/(kg/h),In addition, the maximum
APTT was 121.5s(Fig.1 panel E, arrow). On March 20, 2023. the patient
met weaning criteria. We faced a dilemma at this point: the thrombosis
in the heart is still there, if we wean him from ECMO, there is a high
risk of cardiac arrest. If we do not wean him from ECMO, we need to
maintain systemic anticoagulation therapy and the APTT is significantly
prolonged. Under such circumstances, sustained ECMO may cause lethal
hemorrhage. We carefully evaluated all the risk facing the patient and
determined that the possibility of lethal hemorrhage is much higher than
cardiac arrest so we decided to wean him from ECMO. Then the
anticoagulant regimen was adjusted to enoxaparin 6000iu every 12 hours
hypodermic inject. On March 21,2023, there was no obvious abnormal echo
in the LV with color Doppler echocardiography (Fig.1 panel D, arrow),
and combined with the patient data, thrombosis was diminished after
anticoagulant therapy. On day 13, patient was weaned from mechanical
ventilation and continuing to use enoxaparin 3000iu hypodermic inject
every 12 hours. Subsequently, the patient gradually stabilized and was
discharged on the 29th day of hospitalization with no central
neurological damage, and no other organ system failures.
Conclusions and follow-up
Based on our case and literature analysis, left ventricular thrombosis
is one of the most serious complications during ECMO. At present, the
treatment of left ventricular thrombosis during ECMO mainly includes
drug therapy, surgical thrombectomy, and left ventricular load
unloading, but there are no specific guidelines about this. The volume
of thrombosis in this case is the largest of all surviving cases
reported so far of left ventricular thrombosis during ECMO receiving
non-surgical treatment only (Table.1).
After 3 months of follow-up, the patient’s cardiac ultrasound showed
LVEF was 42% and the formation of a left ventricular posterior wall
aneurysm. After 9 months of follow-up, the patient’s cardiac ultrasound
showed LVEF was 67% and the formation of a left ventricular posterior
wall aneurysm. The patients had no special discomfort during the two
follow-up visits.
Discussion
There were many complications during taking ECMO as a treatment,
including: tearing of large vessels, massive bleeding (30%-70%)
[1], and thrombosis. Left ventricular thrombosis is one of the rare
but serious complications may lead to death. Many factors may cause
thrombosis, and insufficient anticoagulation is one of them. Zhao et al.
[2] suggested that the direct thrombin inhibitors (DTI), e.g.,
heparin, may prevent LV thrombosis. They suggest to use heparin to
prolong the APTT to 50-60s. However, there is still no consensus on the
target of heparin usage. In addition, researchers suggested to use ACT
as monitoring marker to guide the anti-coagulate therapy, but the
controversies are still existence [3-4].
There are very few case reports on ventricular thrombosis of ECMO. We
reviewed previous case reports of left ventricular thrombosis during
ECMO treatment. We used keywords “Left ventricular thrombosis” and
“extracorporeal membrane oxygenation” and retrieved relevant
literatures through PubMed (from 1993 to December 2023). We found only
eight case reports and one review article [5-13]. In these reports
(Table.1), five patients had survived, three patients had deceased. In
one review article, the authors reported patients with heart thrombosis
and all deceased. Among the 5 survived patients, the treatments were
different, one patient [13] was treated by adjusting anticoagulant
to Tenecteplase 30mg administration through a ventilation catheter.
Three patients [5, 9, 10] were received surgical thrombectomy, and
one patient [6] was treated with a new technology -placed retrograde
aortic root catheter for heparin infusion. To our knowledge, our patient
is the only successful case that uses heparin/low molecular heparin to
save the patient from LV thrombosis reported so far. In addition, the
volume of thrombosis in our case is the largest of all reported survival
cases by anticoagulation (Table.1).
In addition, anti-RO-52 antibody and anti-mitochondrial antibody M2
subtype of this patient were found positive in admission. However, there
is no evidence in the literature which anyone can confidently use to
causally link this antibody and thrombosis.