Case report
A 73-year-old man lost consciousness and was transferred to our
hospital. The patient had a history of testicular cancer treated with
chemotherapy 2 years earlier and was in remission. He was barely able to
communicate, and the complaint was unknown. Furthermore, he was in a
shock with cold extremities. Peripheral intravenous infusion was
initiated and transthoracic echocardiography revealed pericardial
effusion and almost no systole. We decided to initiate ECMO based on a
judgment of obstructive shock or cardiogenic shock. Cardiopulmonary
resuscitation (CPR) was started because of CPA, before beginning ECMO.
We also considered emergency left thoracotomy, but ECMO was prioritized.
ECMO circulation was started 17 minutes after arrival and 10 minutes
after CPA. Twelve-lead electrocardiography (ECG) revealed a QS pattern
and ST elevation in leads V1–V5 (Fig. 1). We did not drain the
pericardial fluid, but ECMO flow was stabilized using rapid infusion.
The patient was immediately cooled with ECMO and reached a body
temperature of 34°C 23 minutes after CPA. He was then transferred for
computed tomography (CT) for diagnosis. Contrast-enhanced CT showed no
acute aortic dissection (AAD), and we diagnosed LVFWR due to myocardial
infarction on electrocardiography. No leakage of contrast agent was
apparent (Fig. 2). Blood tests revealed a troponin-I concentration of
13.4 ng/ml (Table); additional blood test results are shown in the
Table. Emergency coronary angiography (CAG) was performed to evaluate
coronary artery lesions and to determine surgical procedures. In the CAG
images, the #7 branch of the left anterior descending coronary artery
(LAD) was chronically totally occluded, and the #4 branch of the right
coronary artery provided collateral circulation to the LAD (Fig. 3).
There was no other significant stenosis, and no rupture point could be
found by left ventricular angiography. An intra-aortic balloon pump
(IABP) was inserted under fluoroscopy, and the patient was immediately
transferred to the operating room for surgical hemostasis.
Under general anesthesia, a skin incision was made from the sternal
notch to the xiphoid process, and the pericardium was exposed by a
median sternotomy. Leakage of bloody pericardial fluid was observed when
the pericardium was incised. The pericardial fluid was aspirated to
remove the blood clots in the pericardium, and oozing blood was observed
near the cardiac apex (Fig. 4). The myocardium around the bleeding point
had poor color tone, but no myocardial necrosis was observed in other
areas. A total of five pieces of TachoSil® (Takeda Pharmaceutical
Company Limited, Tokyo, Japan) were attached, focusing on the bleeding
site, and hemostasis was confirmed (Fig. 4). A towel was inserted into
the pericardium to cover the bleeding area. Next, substernal and
intrapericardial drains were inserted, and a 20-cc syringe was modified
and used as a sternal bridge to prevent boney union. Four pieces of
gauze were also inserted into the subcutaneous space. The skin was not
sutured but instead, was covered with an Esmarch tourniquet and sutured,
and a sterile drape was applied. Negative pressure was applied to the
drain, and the chest was temporarily closed with a vacuum pack.
Considering the possibility of recurrent cardiac tamponade, the patient
was admitted to the intensive care unit (ICU) with temporary chest
closure. There was marked hemorrhagic drainage from the substernal and
pericardial drains, and blood products were supplemented to stabilize
the hemodynamics. TTM lasted 3 days, after which time we discontinued
ECMO, but the consciousness disorder persisted. Waking on the sixth day
of hospitalization, the patient was able to communicate. It was judged
that the left ventricular assisting effect of the IABP had diminished,
and we removed the device. On the same day, the amount of urine started
to increase and diuresis began. Because edema of the mediastinal tissue
and myocardium was controlled, we closed the chest incision on the 9th
day of hospitalization. The patient was extubated on the 14th day of
hospitalization, and on the 15th day of hospitalization, he was
transferred to the general ward without neurological deficits. He is
currently receiving rehabilitation.