Transesophageal Echocardiographic Image of a Retained Fibrin Sleeve After Removal of a Venous Extracorporeal Membrane Oxygenation Cannula Stefaan Bouchez, MD,* G. Burkhard Mackensen, MD, PhD,¶ Filip De Somer, PhD,† Ingrid Herck, MD,‡ and Patrick F. Wouters, MD, PhD* E XTRACORPOREAL MEMBRANE OXYGENATION (ECMO) has gained widespread acceptance and success in improving the outcome of patients in cardiogenic shock and/or respiratory failure. Technologic advances in ECMO have de- creased overall morbidity and mortality, but the risks of throm- bogenic complications and bleeding are still present. The role of echocardiography in the evaluation of thrombus formation on large venous cannulae in the setting of ECMO is poorly described. Transesophageal echocardiographic (TEE) charac- teristics of a retained fibrin sheath after removal of a right atrial venous cannula are reported. CASE REPORT A 43-year-old Caucasian man was admitted with acute chest pain and syncope occurring during recreational bicycling. The patient was unconscious for approximately 1 minute and complained about sustained chest pain and dyspnea after regaining consciousness. There was no history of smoking or drug abuse. He had no medical history and no familial history of cardiovascular disease or sudden death. Coronary angiography showed critical stenosis of the left anterior descending (LAD) coronary artery and occlusion of the right coronary artery (RCA). Percutaneous transluminal coronary angioplasty of the RCA and LAD coronary artery failed, and the patient was transferred for emergent surgical revascularization. After complete revascularization on cardiopulmonary bypass (CPB), weaning from CPB was unsuccessful even after several attempts, maximal inotropic support, and insertion of an intra-aortic balloon pump (IABP). Global myocardial stunning was identified using intraoperative TEE and it was decided to assist the circulation using a venoarterial ECMO. Cannulation for ECMO was by surgical cutdown of the left femoral artery and vein. A femoral venous cannula was placed under TEE guidance and the tip was inserted 2 cm into the superior vena cava (SVC). The ECMO system (Sorin Group, Mirandola, Italy) incorporated a centrifugal pump and a hollow fiber polymethyl pentene membrane oxygenator. After re- moval of the IABP, ECMO was initiated and the patient subse- quently was weaned off CPB. After satisfactory restoration of hemodynamics, the patient was transferred to the intensive care unit (ICU) in stable condition. Anticoagulation with heparin was initi- ated and activated coagulation time (ACT) was kept at 160 to 240 seconds. To optimize heparinization, antithrombin III levels were kept 80% throughout the procedure. In addition to ACT monitor- ing, activated partial thromboplastin time, prothrombin time, fibrin- ogen concentration, platelet count, and a viscoelastic blood coagu- lation measurement (Sonoclot, Sienco, Denver, Co) were performed 2 times a day. Without difficulties, ECMO flows were maintained 2.4 L/min/m 2 throughout the treatment period in the ICU. The patient was kept sedated and a TEE examination was per- formed each day to evaluate left and right ventricular performance. Four days after initiating ECMO, sedation temporarily was held to evaluate the patient’s neurologic status; the patient followed simple commands. Because of continued poor cardiac function and several pulmonary infiltrates, the decision was made to continue ECMO support and sedation for hemodynamic stability. Levosimendan was initiated with low-dose epinephrine. Serial cardiac TEE examina- tions over the next few days showed slow and moderate improve- ment of left ventricular contractility. Spontaneous echocardio- graphic contrast was noted in the apical and mid portions of the left ventricle, and special attention was paid to rule out any thrombo- genic material in the left ventricular apex and at the level of the venous cannula in the right atrium. However, none of the TEE examinations identified any thrombogenic material throughout the course of ECMO treatment. On postoperative day 10, ECMO flow was decreased to about 2.5 L/min (40% of the patient’s calculated normal cardiac output) to evaluate cardiac function. With significantly recovered cardiac function, the patient continued to do well and, after reinsertion of an IABP, was weaned successfully the next day from ECMO. Although cardiac function seemed appropriate by standard hemodynamic monitoring, the decision was made to perform a final TEE exami- nation before weaning the patient from the ventilator. A comprehensive TEE examination during ECMO removal re- vealed a double echo-dense linear structure inside the SVC up to 2 From the Departments of *Anesthesiology, †Cardiac Surgery, and ‡Intensive Care, University Hospital, Ghent, Belgium; and ¶Depart- ment of Anesthesiology, Duke University Medical Center, Durham, NC. Address reprint requests to Stefaan Bouchez, MD, Department of Anesthesia, University Hospital, De Pintelaan, 185, 9000 Ghent, Bel- gium. E-mail: stefaan.bouchez@ugent.be © 2012 Elsevier Inc. All rights reserved. 1053-0770/2605-0023$36.00/0 doi:10.1053/j.jvca.2011.07.006 Key words: transesophageal echocardiography, extracorporeal membrane oxygenation Fig 1. (Left) Midesopha- geal bicaval view of a fibrin sleeve mimicking a venous cannula in the right atrium. (Right) Enlarged right atrial view from the midesophageal 4-chamber view with a cross section through the fibrin sleeve (arrow), which resem- bles the circular shape of the extracorporeal membrane oxy- genation cannula. 883 Journal of Cardiothoracic and Vascular Anesthesia, Vol 26, No 5 (October), 2012: p 883-886