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Lack of efficacy in cardiac disorders: case report A 49-year-old woman exhibited lack of efficacy during inotropic therapy with dopamine and epinephrine after heart transplantation. The woman presented with chronic heart failure and severe left ventricular systolic dysfunction secondary to peripartum cardiomyopathy. Her comorbid conditions included significant for rheumatic heart disease, mechanical mitral valve replacement, mildly hypothermic cardiopulmonary bypass, atrial fibrillation, hypertension and iron deficiency anaemia due to uterine fibroids. After assessment, she was considered for cardiac transplantation and was found to have sickle cell trait (SCT). After the assessment, haematology consult recommended no modification to her perioperative management. Thereafter, she underwent cardiac transplantation. She was weaned from cardiopulmonary bypass (CPB) and was started on unspecified minimal inotropic support. Shortly thereafter, she developed global cardiac dysfunction requiring central veno‐arterial extracorporeal membrane oxygenation (VA-ECMO). An intra-aortic balloon pump (IABP) was inserted through the small right femoral artery and inotropic therapy was escalated. Despite this, she failed to improve and placed on CPB again. Further, she failed weaning from CPB and prompted VA-ECMO. After 15 minutes, due to air-lock in the circuit, a third attempt of CPB was performed. VA‐ECMO was reinstituted, but the circuit stopped suddenly and emergency CPB was performed. Subsequent intraoperative transesophageal‐echocardiogram (TOE) revealed thrombus within the left atrium and ventricle. Therefore, the left atrium was opened and the thrombus was removed with the suction of the left ventricular thrombus under TOE guidance. A third VA‐ECMO circuit was commenced. Then, she transferred to the intensive therapy unit (ITU) with her chest packed due to coagulopathy. At the same time, she started receiving dopamine 5 µg/kg/minute and epinephrine [adrenaline] 0.05 µg/kg/minute [routes not stated]. However, the transplanted heart was asystolic. Subsequently, she was found to have metabolic acidosis requiring haemofiltration and compartment syndrome of the right leg requiring haemostasis. Despite the massive transfusion, her cardiac function did not recover, and she developed multiorgan failure. After the discussion with her family, treatment was discontinued 40h following transfer to the ITU. Eventually, she died. The postmortem revealed extensive myocardial infarction. The cause of death was attributed to catastrophic sickling crisis, with no evidence of hyperacute or acute rejection. Ali JM, et al. Catastrophic sickling crisis in patient undergoing cardiac transplantation with sickle cell trait. American Journal of Transplantation 19: 2378-2382, No. 8, Aug 803506944 2019. Available from: URL: http://doi.org/10.1111/ajt.15379

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Reactions 17 Oct 2020 No. 1826