Modified AngioVac System use With Extracorporeal Membrane Oxygenation in a Child With Fontan Thrombosis

Anesthetic Management for Aspiration Thrombectomy Using the Penumbra Indigo System in Pediatric Patients with Congenital Heart Disease

OBJECTIVE

To describe clinical characteristics and outcomes, including transfusion requirements, in pediatric patients with congenital heart disease undergoing aspiration thrombectomy.

DESIGN

Retrospective chart review.

SETTING

Quaternary academic children's hospital.

PARTICIPANTS

Patients aged <18 years with congenital heart disease undergoing aspiration thrombectomy between November 2017 and February 2022.

MEASUREMENTS AND MAIN RESULTS

Thirteen patients underwent mechanical thrombectomy with the Penumbra Indigo System. Their median age was 3.8 years, and median weight was 15.2 kg. Seven patients had palliated single ventricle circulation, and 6 had biventricular circulation. Nine patients had intensive care unit (ICU) admission before the procedure, and 12 required ICU admission after the procedure. Indications for thrombectomy included systemic venous thrombus in 7 patients, pulmonary arterial thrombus in 3 patients, systemic arterial thrombus in 2 patients, and systemic-to-pulmonary shunt occlusion in 1 patient. The median estimated blood loss was 7.7 mL/kg (interquartile range [IQR], 1.4-15.8 mL/kg; range, 0.5-51.5 mL/kg). Seven patients required intraoperative transfusion of packed red blood cells (n = 4), fresh frozen plasma (n = 2), platelets (n = 3), and/or cryoprecipitate (n = 1). In the patients requiring transfusion, the median transfusion volume was 22 mL/kg (IQR, 14.1-59.7 mL/kg, 9.3-132.8 mL/kg). Thrombectomy was successful in 8 of 13 patients, although 3 of these 8 patients experienced recurrent thrombosis.

CONCLUSIONS

Mechanical aspiration thrombectomy is being increasingly used to treat critically ill pediatric patients and presents unique anesthetic considerations, particularly related to the need for volume and blood product resuscitation.

Percutaneous transeptal mitral valve endocarditis debulking with AngioVac aspiration system

Vacuum assisted aspiration with the AngioVac system has been well described for; right sided endocarditis, venous thrombus, lead related infection/thrombus aspiration and right sided cardiac mass evacuation. Percutaneous transeptal debulking with AngioVac for mitral valve endocarditis (MVE) in the inoperable or high surgical risk patient has not been well defined. A significant proportion of high/prohibitive surgical risk patients with left sided infective endocarditis (IE) are not offered valve surgery as patients in the acute active phase of IE have a high surgical mortality. Nonetheless, sequala of acute IE ie stroke, sepsis or hemodynamic instability in itself is associated with high morbidity and mortality without surgical treatment. A case report of an inoperable patient with methicillin sensitive staphylococcus aureus MVE who was offered MV vegetation debulking with the AngioVac Gen3 C 180 MV system is described. Preprocedural planning with attention to; optimal transeptal height puncture, use of sentinel cerebral protection device to decrease risk of procedure related cerebral embolism and venous extracorporeal membrane cannula, rather than arterial cannula for reinfusion, is described to avoid large bore arterial access related vascular complications. Further studies in a randomized manner are warranted to test these procedural techniques and determine outcomes of percutaneous aspiration of left sided IE with the AngioVac system in this highrisk inoperable cohort of patients.