A case of fulminant perimyocarditis leading to extensive ECMO treatment and spinal injury resulting in paraplegia

In patients supported with peripheral veno-arterial extracorporeal membrane oxygenation, what factors are associated with the development of spinal cord ischaemia?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'in patients supported with peripheral veno-arterial extracorporeal membrane oxygenation, what factors are associated with the development of spinal cord ischaemia'? Altogether, more than 22 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Of the 28 patients reported by included studies, the thoracic spinal cord was most commonly affected. Twenty patients (71%) survived to hospital discharge and 7 (25%) were reported to have neurological recovery. Potential confounders included coronary angiography, cardiac arrest requiring chest compressions and concomitant intra-aortic balloon pump. Consequently, all papers highlighted the likely multifactorial aetiology of spinal cord infarction in these patients. We propose that close neurological observation, particularly in patients who have received chest compressions, and management of potential aetiological factors is crucial to aid in timely diagnosis and potential prevention of this rare complication. Limiting sedation and neuromuscular blockade to enable neurologic assessment of the lower limbs may allow more timely diagnosis.

Spinal cord infarction after withdrawal of veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: A case report

BACKGROUND

Spinal cord infarction is a rare central nervous system angiopathy that impairs motor, sensory, and autonomic nerves and occurs due to various reasons. This study reports a case of spinal cord infarction in a patient following myocardial infarction that was managed by veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

CASE SUMMARY

A 78-year-old Japanese man visited the emergency department with a complaint of chest tightness. He had a history of hypertension, dyslipidemia, diabetes, chronic renal failure, and postoperative bladder cancer. Myocardial infarction was diagnosed after ST elevation in lead aVR was identified by electrocardiogram during the visit, and cardiopulmonary arrest occurred twice during our examination and treatment. After percutaneous coronary intervention with an intra-aortic balloon pump and VA-ECMO, the patient was admitted to the intensive care unit. His circulation stabilized, and he was withdrawn from the intra-aortic balloon pump on day 3 of illness and from VA-ECMO on day 4. However, his consciousness remained impaired. When the patient's consciousness improved on day 14, lower limb weakness was identified. Magnetic resonance imaging conducted on the following day revealed spinal cord infarction in the 5th to 12th thoracic vertebrae.

CONCLUSION

Spinal cord infarction due to VA-ECMO is extremely rare but has a poor neurological prognosis upon onset. Necessary countermeasures include conducting regular neurological examinations and high blood pressure maintenance, which is very difficult in VA-ECMO patients. Therefore, patient care will benefit from the experiences reported in such cases.

Spinal cord infarction and peripheral extracorporeal membrane oxygenation: a case series

Background

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is increasingly utilized in patients with cardiogenic shock due to improved technology and outcomes. Peripheral VA ECMO offers several advantages over central ECMO and is becoming increasingly popular. However, when configured via the femoral vessels, retrograde flow to the descending aorta and arch of aorta competes with antegrade ventricular output and can be associated with a watershed phenomenon and increased risk of neurologic and visceral injury.

Case summary

In this case series, we report three patients who were supported with peripheral VA ECMO for cardiogenic shock. All three were successfully weaned from peripheral VA ECMO; however, they had developed bilateral lower limb paralysis. Magnetic resonance imaging revealed spinal cord infarction in all three patients. All patients subsequently succumbed to multiorgan failure and did not survive to hospital discharge.

Discussion

The use of mechanical circulatory support, in particular, peripheral ECMO, has escalated with advances in technology, better understanding of cardiac physiology and improving outcomes. Spinal cord infarction is a rare but serious complication of peripheral VA ECMO support with only a few case reports published. Further studies are needed to identify the exact cause and prevention of this rare but often terminal complication. Through this series of three patients supported on peripheral VA ECMO complicated by spinal cord infarction, we review previously published reports, analyse possible mechanisms, and propose alternate management strategies to be considered in patients at risk.

Spinal Cord Infarction During Femoral Venoarterial Extracorporeal Membrane Oxygenation

We describe 4 cases of spinal cord ischemia resulting in paraplegia after peripheral venoarterial extracorporeal membrane oxygenation for cardiogenic shock. This is an uncommon, but possibly underreported, complication with significant irreversible long-term morbidity. While causes are likely multifactorial, it is possible that thrombosis may occur at the level of the mixing cloud due to turbulent flow. Additional studies will be needed to elucidate the true incidence of this complication and investigate whether flow dynamics may potentiate clot formation.

Spinal cord infarction during venoarterial-extracorporeal membrane oxygenation support

Spinal cord infarction (SCI) is a rare disease among central nervous system vascular diseases. Only a little is known about venoarterial extracorporeal membrane oxygenation (VA-ECMO)-related SCI. Retrospective observational study conducted, from 2006 to 2019, in a tertiary referral center on patients who developed VA-ECMO-related neurovascular complications, focusing on SCI. During this period, among the 1893 patients requiring VA-ECMO support, 112 (5.9%) developed an ECMO-related neurovascular injury: 65 (3.4%) ischemic strokes, 40 (2.1%) intracranial bleeding, one cerebral thrombophlebitis (0.05%) and 6 (0.3%) spinal cord infarction. Herein, we report a series of six patients with refractory cardiogenic shock or cardiac arrest receiving circulatory support with VA-ECMO who developed subsequent SCI during ECMO course, confirmed by spine MRI after ECMO withdrawal. All six patients had long-term neurological disabilities. VA-ECMO-related SCI is a rare but catastrophic complication. Its diagnosis is usually delayed due to sedation requirement and/or ICU acquired weakness after sedation withdrawal, leading to difficulties in monitoring their neurological status. Even if no specific treatment exist for SCI, its prompt diagnosis is mandatory, to prevent secondary spine insults of systemic origin. Based on these results, we suggest that daily sedation interruption and neurological exam of the lower limbs should be performed in all VA-ECMO patients. Large registries are mandatory to determine VA-ECMO-related SCI risk factor and potential therapy.