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.