Skip to main content
  • American Heart Association
  • Science Volunteer
  • Warning Signs
  • Advanced Search
  • Donate

  • Home
  • About this Journal
    • Editorial Board
    • General Statistics
    • Information for Advertisers
    • Author Reprints
    • Commercial Reprints
    • Customer Service and Ordering Information
  • All Issues
  • Subjects
    • All Subjects
    • Arrhythmia and Electrophysiology
    • Basic, Translational, and Clinical Research
    • Critical Care and Resuscitation
    • Epidemiology, Lifestyle, and Prevention
    • Genetics
    • Heart Failure and Cardiac Disease
    • Hypertension
    • Imaging and Diagnostic Testing
    • Intervention, Surgery, Transplantation
    • Quality and Outcomes
    • Stroke
    • Vascular Disease
  • Browse Features
    • AHA Guidelines and Statements
    • Emerging Investigators
    • Advances in Heart Failure
    • On My Mind
    • Images and Case Reports in Heart Failure
  • Resources
    • Instructions for Authors
      • Accepted Manuscripts
      • Revised Manuscripts
    • → Article Types
    • → General Preparation Instructions
    • → Research Guidelines
    • → How to Submit a Manuscript
    • Journal Policies
    • Permissions and Rights Q&A
    • Submission Sites
    • AHA Journals RSS Feeds
    • International Users
    • AHA Newsroom
  • AHA Journals
    • AHA Journals Home
    • Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB)
    • Circulation
    • → Circ: Arrhythmia and Electrophysiology
    • → Circ: Genomic and Precision Medicine
    • → Circ: Cardiovascular Imaging
    • → Circ: Cardiovascular Interventions
    • → Circ: Cardiovascular Quality & Outcomes
    • → Circ: Heart Failure
    • Circulation Research
    • Hypertension
    • Stroke
    • Journal of the American Heart Association
  • Twitter

  • My alerts
  • Sign In
  • Join

  • Advanced search

Header Publisher Menu

  • American Heart Association
  • Science Volunteer
  • Warning Signs
  • Advanced Search
  • Donate

Circulation:
Heart Failure

  • My alerts
  • Sign In
  • Join

  • Twitter
  • Home
  • About this Journal
    • Editorial Board
    • General Statistics
    • Information for Advertisers
    • Author Reprints
    • Commercial Reprints
    • Customer Service and Ordering Information
  • All Issues
  • Subjects
    • All Subjects
    • Arrhythmia and Electrophysiology
    • Basic, Translational, and Clinical Research
    • Critical Care and Resuscitation
    • Epidemiology, Lifestyle, and Prevention
    • Genetics
    • Heart Failure and Cardiac Disease
    • Hypertension
    • Imaging and Diagnostic Testing
    • Intervention, Surgery, Transplantation
    • Quality and Outcomes
    • Stroke
    • Vascular Disease
  • Browse Features
    • AHA Guidelines and Statements
    • Emerging Investigators
    • Advances in Heart Failure
    • On My Mind
    • Images and Case Reports in Heart Failure
  • Resources
    • Instructions for Authors
    • → Article Types
    • → General Preparation Instructions
    • → Research Guidelines
    • → How to Submit a Manuscript
    • Journal Policies
    • Permissions and Rights Q&A
    • Submission Sites
    • AHA Journals RSS Feeds
    • International Users
    • AHA Newsroom
  • AHA Journals
    • AHA Journals Home
    • Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB)
    • Circulation
    • → Circ: Arrhythmia and Electrophysiology
    • → Circ: Genomic and Precision Medicine
    • → Circ: Cardiovascular Imaging
    • → Circ: Cardiovascular Interventions
    • → Circ: Cardiovascular Quality & Outcomes
    • → Circ: Heart Failure
    • Circulation Research
    • Hypertension
    • Stroke
    • Journal of the American Heart Association
Images and Case Reports in Heart Failure

Ventricular Thrombosis Post-Venoarterial Extracorporeal Membrane Oxygenation

Mosaad Alhussein, Yasbanoo Moayedi, Juan Duero Posada, Heather Ross, Edward Hickey, Vivek Rao, Filio Billia
Download PDF
https://doi.org/10.1161/CIRCHEARTFAILURE.116.003757
Circulation: Heart Failure. 2017;10:e003757
Originally published February 10, 2017
Mosaad Alhussein
From the Ted Rogers Centre for Heart Research (M.A., Y.M., J.D.P., H.R., F.B.) and Division of Cardiac Surgery (V.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; and Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada (E.H.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Yasbanoo Moayedi
From the Ted Rogers Centre for Heart Research (M.A., Y.M., J.D.P., H.R., F.B.) and Division of Cardiac Surgery (V.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; and Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada (E.H.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Juan Duero Posada
From the Ted Rogers Centre for Heart Research (M.A., Y.M., J.D.P., H.R., F.B.) and Division of Cardiac Surgery (V.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; and Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada (E.H.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Heather Ross
From the Ted Rogers Centre for Heart Research (M.A., Y.M., J.D.P., H.R., F.B.) and Division of Cardiac Surgery (V.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; and Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada (E.H.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Edward Hickey
From the Ted Rogers Centre for Heart Research (M.A., Y.M., J.D.P., H.R., F.B.) and Division of Cardiac Surgery (V.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; and Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada (E.H.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Vivek Rao
From the Ted Rogers Centre for Heart Research (M.A., Y.M., J.D.P., H.R., F.B.) and Division of Cardiac Surgery (V.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; and Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada (E.H.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Filio Billia
From the Ted Rogers Centre for Heart Research (M.A., Y.M., J.D.P., H.R., F.B.) and Division of Cardiac Surgery (V.R.), Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; and Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada (E.H.).
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Tables
  • Supplemental Materials
  • Info & Metrics
  • eLetters

Jump to

  • Article
    • Introduction
    • Case 1
    • Case 2
    • Case 3
    • Discussion
    • Summary
    • Disclosures
    • Footnotes
    • References
  • Figures & Tables
  • Supplemental Materials
  • Info & Metrics
  • eLetters
Loading
  • chest pain
  • coronary angiography
  • echocardiography
  • heart failure
  • pulmonary artery

Introduction

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for the support of critically ill patients with cardiogenic shock is rapidly increasing. Intracardiac thrombus formation is a well-recognized complication. We present 3 cases of dramatic intracardiac thrombosis after the initiation of VA-ECMO.

Case 1

A 64-year-old man presented to a community hospital 3 days after the onset of chest pain with ECG evidence of anterior ST-elevation–myocardial infarction and clinical findings of cardiogenic shock. Physical examination was notable for a pansystolic murmur suggestive of a ventricular septal defect. Coronary angiography showed an occluded left anterior descending artery. Echocardiography confirmed an ischemic ventricular septal defect. He was taken urgently to the operating room for aortocoronary bypass and ventricular septal defect patch repair. Attempts to wean off cardiopulmonary bypass were unsuccessful, and the patient was placed on central VA-ECMO as a bridge to decision, with the chest left open. Forty-eight hours after the initiation of ECMO, the circuit was converted to a peripheral set-up to facilitate chest closure. Transesophageal echocardiogram performed 24 hours after chest closure showed complete thrombosis of the right ventricle despite full anticoagulation (Figure [A]; Movie I in the Data Supplement). He was taken back to the operating room. On direct visualization, thrombus was present in the right ventricle extending into the main pulmonary artery and its branches. After extensive multidisciplinary review, he was deemed not suitable for definitive management with transplantation or durable mechanical support given the extensive thrombosis in the pulmonary circulation. Philosophy of care changed to intensification of comfort measures, and the patient expired in the intensive care unit.

Figure.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure.

Echocardiograms of intracardiac thrombus in patients supported with venoarterial extracorporeal membrane oxygenation. Representative echocardiograms of patients in cases 1 through 3. Transesophageal (A) and transthoracic (B and C) echocardiograms depicting hyperechoic material within the ventricular cavity, consistent with acute thrombosis.

Case 2

A 49-year-old woman presented to the emergency room with a 1-week history of nonspecific symptoms and acute onset chest pain. ECG showed anterior ST-elevation–myocardial infarction. The patient was taken urgently to the catheterization laboratory where coronary angiography revealed an acute thrombotic occlusion of the left anterior descending and femoral arteries, suggesting a prothrombotic state. Because of hemodynamic deterioration and the development of cardiogenic shock, the patient was placed on peripheral (femoral) VA-ECMO. Anticoagulation was started. Echocardiography 1 day post-cannulation showed complete thrombosis of the left ventricle (Figure [B]; Movie II in the Data Supplement). In spite of the extracorporeal circuit, the patient developed progressive multiorgan failure and died the next day.

Case 3

A 46-year-old man, lost to follow-up after childhood Tetralogy of Fallot repair, presented with an abrupt history of severe, decompensated heart failure. Investigations demonstrated severe biventricular dysfunction, an 8.2-cm ascending aortic aneurysm and severe regurgitation of the aortic and pulmonary valves. The patient underwent emergency modified tissue Bentall procedure and tissue pulmonic valve replacement. The aneurysm was so large that the left main coronary ostium was distorted with acute angulation and slit-like orifice, and therefore, a left ostioplasty was undertaken. After separation from bypass, a low cardiac output state and ischemic ECG changes prompted coronary angiography which revealed left main ostial stenosis. Salvage left main stent insertion failed to prevent the patient’s deterioration, and an emergent left femoral VA-ECMO was implemented. Six days post-ECMO cannulation, echocardiography showed no appreciable recovery in ventricular function, and conversion to ventricular assist device was therefore entertained. However, before operation, transthoracic echocardiography demonstrated near complete thrombosis of the left ventricle despite routine anticoagulation (Figure [C]; Movie III in the Data Supplement). The clot was evacuated via a ventriculotomy, and Centrimag support was initiated via left ventricular aortic cannulation. The patient eventually had a durable HeartWare left ventricular assist device implanted at a later date. He was discharged home and is recovering well.

Discussion

The application of extracorporeal membrane oxygenation (ECMO) for critical cardiogenic shock is increasing worldwide. In 2015, there were 2167 adult cases reported requiring extracorporeal life support in the Extracorporeal Life Support Organization registry for cardiac indications.1 ECMO may provide support as a bridge to recovery, as a bridge to decision, or as a bridge to advanced heart failure therapies. In observational trials, although patients had improved survival, mortality is significantly higher in patients who required ECMO for >3 days.2

Many complications associated with ECMO use have been reported, including bleeding, cannulation site complications, brain and coronary hypoxia, and thromboembolism. Circulatory support with an ECMO circuit may predispose to the development of intracardiac thrombosis by different mechanisms, all of which may involve ≥1 components of Virchow triad. The prevalence of intracardiac thrombosis while on ECMO support has not been systematically documented in the literature. Its occurrence, however, has been noted in a growing number of case reports as a reflection of the increasing utilization of this technology.3 Active surveillance for the development of spontaneous echo contrast and strategies that minimize its occurrence may decrease the risk of intracardiac thrombus formation and the potential for systemic embolization.

The Extracorporeal Life Support Organization registry has published recommendations on optimal anticoagulation management for patients on ECMO that includes the use of intravenous heparin with titration to achieve an activated clotting time of 180 to 220 s. However, these recommendations are often modified in response to patient-specific clinical scenarios.

Routine cardiac decompression may prevent ventricular thrombus formation in patients at risk of ventricular distention. These include patients with aortic regurgitation, high afterload, and the absence of ejection.4 Although different modalities to achieve decompression have been described, once intracardiac thrombus is present, the optimal treatment for such patients is unknown and may include surgical removal.

Summary

We present 3 dramatic cases of intracardiac thrombosis while on VA-ECMO support. Early recognition, aggressive venting strategies, and anticoagulation are important to possibly prevent this frequently lethal complication.

Disclosures

None.

Footnotes

  • The Data Supplement is available at http://circheartfailure.ahajournals.org/lookup/suppl/doi10.1161/CIRCHEARTFAILURE.116.003757/-/DC1.

  • Received November 29, 2016.
  • Accepted January 20, 2017.
  • © 2017 American Heart Association, Inc.

References

  1. 1.↵
    1. Thiagarajan RR,
    2. Barbaro RP,
    3. Rycus PT,
    4. Mcmullan DM,
    5. Conrad SA,
    6. Fortenberry JD,
    7. Paden ML
    ; ELSO Member Centers. Extracorporeal Life Support Organization Registry International Report 2016. ASAIO J. 2017;63:60–67. doi: 10.1097/MAT.0000000000000475.
    OpenUrl
  2. 2.↵
    1. Chang CH,
    2. Chen HC,
    3. Caffrey JL,
    4. Hsu J,
    5. Lin JW,
    6. Lai MS,
    7. Chen YS.
    . Survival analysis after extracorporeal membrane oxygenation in critically ill adults: A Nationwide Cohort Study. Circulation. 2016;133:2423–2433. doi: 10.1161/CIRCULATIONAHA.115.019143.
    OpenUrlAbstract/FREE Full Text
  3. 3.↵
    1. Weis F,
    2. Beiras-Fernandez A,
    3. Bruegger D,
    4. Kreth S,
    5. Sodian R,
    6. Kur F,
    7. Weis M,
    8. Nikolaou K.
    . Huge intracardiac thrombosis in a patient on veno-arterial extracorporeal membrane oxygenation support. Interact Cardiovasc Thorac Surg. 2009;8:247–249. doi: 10.1510/icvts.2008.193391.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    1. Rupprecht L,
    2. Flörchinger B,
    3. Schopka S,
    4. Schmid C,
    5. Philipp A,
    6. Lunz D,
    7. Müller T,
    8. Camboni D.
    . Cardiac decompression on extracorporeal life support: a review and discussion of the literature. ASAIO J. 2013;59:547–553. doi: 10.1097/MAT.0b013e3182a4b2f6.
    OpenUrlCrossRefPubMed
View Abstract
Back to top
Previous ArticleNext Article

This Issue

Circulation: Heart Failure
February 2017, Volume 10, Issue 2
  • Table of Contents
Previous ArticleNext Article

Jump to

  • Article
    • Introduction
    • Case 1
    • Case 2
    • Case 3
    • Discussion
    • Summary
    • Disclosures
    • Footnotes
    • References
  • Figures & Tables
  • Supplemental Materials
  • Info & Metrics
  • eLetters

Article Tools

  • Print
  • Citation Tools
    Ventricular Thrombosis Post-Venoarterial Extracorporeal Membrane Oxygenation
    Mosaad Alhussein, Yasbanoo Moayedi, Juan Duero Posada, Heather Ross, Edward Hickey, Vivek Rao and Filio Billia
    Circulation: Heart Failure. 2017;10:e003757, originally published February 10, 2017
    https://doi.org/10.1161/CIRCHEARTFAILURE.116.003757

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
  •  Download Powerpoint
  • Article Alerts
    Log in to Email Alerts with your email address.
  • Save to my folders

Share this Article

  • Email

    Thank you for your interest in spreading the word on Circulation: Heart Failure.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Ventricular Thrombosis Post-Venoarterial Extracorporeal Membrane Oxygenation
    (Your Name) has sent you a message from Circulation: Heart Failure
    (Your Name) thought you would like to see the Circulation: Heart Failure web site.
  • Share on Social Media
    Ventricular Thrombosis Post-Venoarterial Extracorporeal Membrane Oxygenation
    Mosaad Alhussein, Yasbanoo Moayedi, Juan Duero Posada, Heather Ross, Edward Hickey, Vivek Rao and Filio Billia
    Circulation: Heart Failure. 2017;10:e003757, originally published February 10, 2017
    https://doi.org/10.1161/CIRCHEARTFAILURE.116.003757
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo

Related Articles

Cited By...

Subjects

  • Heart Failure and Cardiac Disease
    • Heart Failure
    • Cardiomyopathy

Circulation: Heart Failure

  • About Circulation: Heart Failure
  • Instructions for Authors
  • AHA CME
  • Guidelines and Statements
  • Permissions
  • Journal Policies
  • Email Alerts
  • Open Access Information
  • AHA Journals RSS
  • AHA Newsroom

Editorial Office Address:
200 Fifth Avenue, Suite 1020
Waltham, MA 02451 
email: circ@circulationjournal.org

Information for:
  • Advertisers
  • Subscribers
  • Subscriber Help
  • Institutions / Librarians
  • Institutional Subscriptions FAQ
  • International Users
American Heart Association Learn and Live
National Center
7272 Greenville Ave.
Dallas, TX 75231

Customer Service

  • 1-800-AHA-USA-1
  • 1-800-242-8721
  • Local Info
  • Contact Us

About Us

Our mission is to build healthier lives, free of cardiovascular diseases and stroke. That single purpose drives all we do. The need for our work is beyond question. Find Out More about the American Heart Association

  • Careers
  • SHOP
  • Latest Heart and Stroke News
  • AHA/ASA Media Newsroom

Our Sites

  • American Heart Association
  • American Stroke Association
  • For Professionals
  • More Sites

Take Action

  • Advocate
  • Donate
  • Planned Giving
  • Volunteer
  • You're the Cure

Online Communities

  • AFib Support
  • Empowered to Serve
  • Garden Community
  • Patient Support Network
  • Professional Online Network

Follow Us:

  • Follow Circulation on Twitter
  • Visit Circulation on Facebook
  • Follow Circulation on Google Plus
  • Follow Circulation on Instagram
  • Follow Circulation on Pinterest
  • Follow Circulation on YouTube
  • Rss Feeds
  • Privacy Policy
  • Copyright
  • Ethics Policy
  • Conflict of Interest Policy
  • Linking Policy
  • Diversity
  • Careers

©2018 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. The American Heart Association is a qualified 501(c)(3) tax-exempt organization.
*Red Dress™ DHHS, Go Red™ AHA; National Wear Red Day ® is a registered trademark.

  • PUTTING PATIENTS FIRST National Health Council Standards of Excellence Certification Program
  • BBB Accredited Charity
  • Comodo Secured