Successful administration of venovenous extracorporeal membrane oxygenation through the modified Blalock-Taussig operation in an infant with graft dysfunction after the Norwood procedure.

Dear editor

Insufficient pulmonary blood flow through a right ventricle-to-pulmonary artery conduit following the Norwood procedure is remediable by adding a modified Blalock–Taussig shunt (MBTS).1 First, however, perioperative hypoxemia must be managed. Venovenous extracorporeal membrane oxygenation (VV-ECMO) is likely to be a useful method for respiratory support in such cases.2,3 We present the case of a 2-month-old patient with graft dysfunction after the Norwood procedure who underwent MBTS with VV-ECMO support.

Case report

Due to graft dysfunction after the Norwood operation, a 2-month-old female infant (height 49 cm, weight 3.1 kg) was scheduled for an emergency right MBTS. VV-ECMO was also planned to avoid the risk of perioperative hypoxemia. After anesthetic induction, an 8 Fr bicaval dual-lumen catheter (GamCath® pediatric catheter; Gambro, Lund, Sweden) was placed in the right internal jugular vein under ultrasound guidance and VV-ECMO was implemented.4,5 Transesophageal echocardiography was used to evaluate the ventricular function and volume status, along with the hemodynamics. Upon initiation of VV-ECMO, the drainage flow volume temporarily decreased. A volume challenge was immediately performed with 5% albumin to achieve an appropriate preload. The hemodynamic responses were monitored by transesophageal echocardiography.6 The VV-ECMO circuit became stable after the volume load. The VV-ECMO flow rate was maintained at 150 mL/min, with the rotor at 3000 rpm. During right pulmonary artery clamping, the oxygen saturation improved to approximately 90%, with a pO2 of 313 mmHg on a FiO2 of 1. The MBTS was successfully performed. Subsequent VV-ECMO weaning was uneventful. VV-ECMO was finally withdrawn due to persistent stability of the patient’s hemodynamic status.

Conclusion

VV-ECMO is an effective management strategy not only for adults but also for infants with refractory cardiorespiratory failure. Based on our experience with this patient, VV-ECMO provides useful respiratory support to avoid hypoxemia during MBTS operation in infants with graft dysfunction after the Norwood procedure.