Veno-arterial extracorporeal membrane oxygenationas a bridge to cytolytic therapy
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CASE REPORT
Veno-arterial extracorporeal membrane oxygenation as a bridge to cytolytic therapy Chirantan Mangukia 1 Yoshiya Toyoda 1
&
Stacey Brann 1 & Shrey Patel 1 & Fredric Jaffe 2 & Jeffrey Stewart 2 & Gengo Sunagawa 1 &
Received: 18 April 2020 / Revised: 15 June 2020 / Accepted: 19 June 2020 # Indian Association of Cardiovascular-Thoracic Surgeons 2020
Abstract We describe a case of successful use of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO), as a bridge to cytoreductive therapy, in a patient with large mediastinal mass due to T cell lymphoblastic leukemia, complicated by acute cardiorespiratory compromise from mechanical compression and pulmonary embolism. Keywords VA ECMO . Mediastinal neoplasms . Pulmonary embolism . Cytolytic therapy
Introduction
Case report
Large anterior mediastinal mass causing compression on vital structures like trachea, superior vena cava, pulmonary artery, right atrium, etc. is always challenging to manage. When indicated, surgical removal of such masses often requires mechanical circulatory support in the form of cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO). However, a large proportion of these tumors are lymphoma and leukemia, for which chemotherapy or cytolytic therapy is very effective. While undergoing or waiting for cytolytic therapy, these patients are at significant risk of sudden cardiorespiratory collapse because of critical compression of vital structures. We report a similar case here.
A 21-year-old female was referred to our hospital with complaints of rapidly progressing shortness of breath and recent onset of dysphagia to solid food for the last 1 month. She had also noted progressive swelling of her face, hands, and lower extremities over the past few weeks. Her past medical history was significant for tonsillectomy and bronchial asthma, for which she was taking albuterol inhaler occasionally. She was an inconsistent smoker, not more than half a pack/day, for the last 2 years and was undergoing deaddiction treatment with nicotine patch. Computed tomography (CT) angiogram showed a large anterior mediastinal soft tissue mass causing rightward deviation and compression of the trachea and esophagus, partial collapse of left upper and lower lobes, and large left pleural effusion (Fig. 1a). The mass was also found to be causing compression on the main pulmonary artery and right ventricular outflow tract (Fig. 1b). CT also revealed extensive retrocrural and periaortic lymphadenopathy. Left thoracostomy tube drained a liter of straw-colored fluid. Cytology from pleural fluid showed abundant intermediate-sized lymphocytes, without Reed-Sternberg cells. CT-guided biopsy showed T cell lymphoblastic lymphoma. Baseline lactate dehydrogenase was 641 units/L with normal ß-hCG levels. Four hours after CT-guided biopsy, the patient had a syncopal attack followed by sudden increase in breathlessness. Electrocardiogram showed sinus tachycardia, and pulse oximetry showed profound hypoxia. She was immediately transferred to the Intensi
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