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Mechanism of stroke in the setting of postcardiotomy venoarterial extracorporeal membrane oxygenation support

Open AccessPublished:April 12, 2022DOI:https://doi.org/10.1016/j.xjon.2022.04.002
      To the Editor:
      The authors reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
      With great interest we read the study by Schaefer and colleauges,
      • Schaefer A.-K.
      • Distelmaier K.
      • Riebandt J.
      • Goliasch G.
      • Bernardi M.H.
      • Zimpfer D.
      • et al.
      Access site complications of postcardiotomy extracorporeal life support.
      who conducted a detailed analysis of the outcomes of postcardiotomy venoarterial extracorporeal membrane oxygenation (VA-ECMO) support focusing on stroke and cannulation-related complications. The stroke rate of right axillary (RAX) VA-ECMO was greater than that of femoral cannulation. In both axillary and femoral VA-ECMO, the right hemisphere was the most common stroke location (64.5% in RAX and 50% in femoral). This stroke laterality trend in RAX cannulation was similar in our experiences.
      • Ohira S.
      • Malekan R.
      • Goldberg J.B.
      • Lansman S.L.
      • Spielvogel D.
      • Kai M.
      Axillary artery cannulation for venoarterial extracorporeal membrane oxygenation in cardiogenic shock.
      ,
      • Ohira S.
      • Spielvogel D.
      • Malekan R.
      • Goldberg J.B.
      • Spencer P.J.
      • Lansman S.L.
      • et al.
      Impact of mitral valve prosthesis on stroke after insertion of venoarterial membrane oxygenation for postcardiotomy shock.
      There are several potential embolic sources in the setting of postcardiotomy VA-ECMO support: VA-ECMO–related (circuit, tubing, or cannula), intracardiac, or arterial/aortic (atherosclerosis, suture line, or intraoperative cannulation site).
      • Ohira S.
      • Spielvogel D.
      • Malekan R.
      • Goldberg J.B.
      • Spencer P.J.
      • Lansman S.L.
      • et al.
      Impact of mitral valve prosthesis on stroke after insertion of venoarterial membrane oxygenation for postcardiotomy shock.
      Another possible mechanism of stroke in RAX VA-ECMO may be the “mixing point” between VA-ECMO flow and blood flow ejected from the heart, which can be an issue when heart function is recovered together with lower VA-ECMO flow. We experienced an occlusion of the innominate artery to the right common carotid artery after recovery of heart function in a patient postcardiotomy using RAX VA-ECMO (Figure 1).
      Figure thumbnail gr1
      Figure 1A male patient required venoarterial extracorporeal membrane oxygenation (VA-ECMO) via the right axillary artery due to postcardiotomy shock after ischemic ventricular septal defect repair. On postoperative day 2, with recovery of left ventricular function, the patient suddenly developed left hemiparesis with a dropped VA-ECMO flow. Emergent computed tomography (A) showed occlusion of the innominate artery (arrows) to the right common carotid artery. A brain perfusion scan showed a complete occlusion of the right middle cerebral artery system (red area in B). An arrowhead shows the left subclavian artery.
      In addition to VA-ECMO itself, the type of surgery performed is also important when discussing the cause of stroke; left-side valve surgery using prosthesis or patients with reduced ejection fraction would have a greater chance of developing an intracardiac embolic source.
      • Ohira S.
      • Spielvogel D.
      • Malekan R.
      • Goldberg J.B.
      • Spencer P.J.
      • Lansman S.L.
      • et al.
      Impact of mitral valve prosthesis on stroke after insertion of venoarterial membrane oxygenation for postcardiotomy shock.
      ,
      • Challa A.
      • Latona J.
      • Fraser J.
      • Spanevello M.
      • Scalia G.
      • Burstow D.
      • et al.
      Mitral valve bio-prosthesis and annuloplasty thrombosis during extracorporeal membrane oxygenation: case series.
      It would have been informative if the authors could have included the type of surgery in Table E6 of their article. We agree with their conclusion that surgeons understand that each configuration has advantages and disadvantages over the other, depending on the scenario of the individual.

      References

        • Schaefer A.-K.
        • Distelmaier K.
        • Riebandt J.
        • Goliasch G.
        • Bernardi M.H.
        • Zimpfer D.
        • et al.
        Access site complications of postcardiotomy extracorporeal life support.
        J Thorac Cardiovasc Surg. November 15, 2021; ([Epub ahead of print])
        • Ohira S.
        • Malekan R.
        • Goldberg J.B.
        • Lansman S.L.
        • Spielvogel D.
        • Kai M.
        Axillary artery cannulation for venoarterial extracorporeal membrane oxygenation in cardiogenic shock.
        J Thorac Cardiovasc Surg Tech. 2020; 5: 62-71
        • Ohira S.
        • Spielvogel D.
        • Malekan R.
        • Goldberg J.B.
        • Spencer P.J.
        • Lansman S.L.
        • et al.
        Impact of mitral valve prosthesis on stroke after insertion of venoarterial membrane oxygenation for postcardiotomy shock.
        J Heart Lung Transplant. 2021; 40: S407
        • Challa A.
        • Latona J.
        • Fraser J.
        • Spanevello M.
        • Scalia G.
        • Burstow D.
        • et al.
        Mitral valve bio-prosthesis and annuloplasty thrombosis during extracorporeal membrane oxygenation: case series.
        Eur Heart J Case Rep. 2020; 4: 1-6

      Linked Article

      • Access site complications of postcardiotomy extracorporeal life support
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 5
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          To assess the influence of primary arterial access in patients receiving peripheral postcardiotomy extracorporeal life support on associated complications and outcome.
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      • Reply from authors: Attempting to solve the puzzle—How to unveil the truth about the origin of stroke in postcardiotomy extracorporeal life support?
        JTCVS OpenVol. 11
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          In our series of patients on postcardiotomy extracorporeal life support (ECLS), we described predominantly right hemispheric strokes in patients cannulated via the axillary artery. In accordance with our results, Grunfeld and colleagues1 shared their experience and stress the role of primary procedure in the likelihood of developing ECLS-related stroke. Furthermore, they described a case of innominate artery occlusion in a patient with axillary artery ECLS cannulation recovering cardiac function, shifting interest on the flow phenomena in the watershed zone during weaning, and possible relation to stroke.
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      • Reply: Right, wrong, or somewhere in between?
        JTCVS OpenVol. 11
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          Grunfeld and colleagues1 provide interesting insight on a potential mechanism for observed increases in right-sided stroke that were recently reported during right axillary venoarterial extracorporeal membrane oxygenation (ECMO).2 In addition to embolization, they suggest that mixing between ECMO flow and the native cardiac output may produce an environment predisposing to right-sided stroke, including through blood stasis and leading to innominate artery thrombosis, supported by compelling clinical images.
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