Case Report| Volume 25, ISSUE 5, P282-284, May 2022

Thrombosed stuck mitral valve during advanced mechanical circulatory support for post-cardiotomy shock

Published:December 16, 2021DOI:


      We report a case of mechanical prosthetic mitral valve thrombosis in a 52-year-old woman with previous diagnosis of dilated cardiomyopathy, who was supported with advanced mechanical circulatory support after urgent mechanical mitral valve replacement (MVR) and tricuspid annuloplasty. Difficult weaning from cardiopulmonary bypass needed support with veno-arterial extracorporeal membranous oxygenation and Impella (Abiomed Inc, Danvers, MA, USA), so-called ECPELLA. Temporary discontinuation of heparin and massive blood transfusion were necessary due to four times of reoperation for bleeding during ECPELLA support. Poor recovery of cardiac function needed escalation from ECPELLA to extracorporeal biventricular assist device (ex-BiVAD) using two centrifugal pumps on Day 12. After gradual decrease in the left ventricular assist device flow, transesophageal echocardiography and fluoroscopic images revealed the stuck leaflets of the mitral prosthesis. Therefore, the patient underwent re-MVR with a bioprosthesis on Day 18, followed by continued assistance with ex-BiVAD. The patient was finally weaned from ex-BiVAD on Day 28 and was transferred to the referral hospital for rehabilitation. She was alive in good general condition at 2-year follow-up. It is important to balance the effects of anticoagulation on advanced mechanical circulatory support with ECPELLA, against the side effects of bleeding, especially in post-cardiotomy patients with bleeding tendency.
      <Learning objective: We should recognize the fatal risks of bleeding and thrombosis during advanced mechanical support, including Impella, VA-ECMO, ECPELLA, and ex-BiVAD, especially in the post-cardiotomy setting. We should also understand the choice of mechanical circulatory support, timely escalation to ex-BiVAD to avoid multiorgan failure, the diagnosis of mechanical mitral prosthetic thrombosed valve using echocardiography and fluoroscopy, and mitral valve replacement in the patient supported with ex-BiVAD.>


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        • Raffa GM
        • Kowalewski M
        • Brodie D
        • Ogino M
        • Whitman G
        • Meani P
        • Pilato M
        • Arcadipane A
        • Delnoij T
        • Natour E
        • Gelsomino S
        • Maessen J
        • Lorusso R.
        Meta-analysis of peripheral or central extracorporeal membrane oxygenation in postcardiotomy and non-postcardiotomy shock.
        Ann Thorac Surg. 2019; 107: 311-321
        • Russo JJ
        • Aleksova N
        • Pitcher I
        • Couture E
        • Parlow S
        • Faraz M
        • Visintini S
        • Simard T
        • Di Santo P
        • Mathew R
        • So DY
        • Takeda K
        • Garan AR
        • Karmpaliotis D
        • Takayama H
        • et al.
        Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock.
        J Am Coll Cardiol. 2019; 73: 654-662
        • Pappalardo F
        • Schulte C
        • Pieri M
        • Schrage B
        • Contri R
        • Soeffker G
        • Greco T
        • Lembo R
        • Müllerleile K
        • Colombo A
        • Sydow K
        • De Bonis M
        • Wagner F
        • Reichenspurner H
        • Blankenberg S
        • et al.
        Concomitant implantation of Impella® on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock.
        Eur J Heart Fail. 2017; 19: 404-412
        • Patel SM
        • Lipinski J
        • Al-Kindi SG
        • Patel T
        • Saric P
        • Li J
        • Nadeem F
        • Ladas T
        • Alaiti A
        • Phillips A
        • Medalion B
        • Deo S
        • Elgudin Y
        • Costa MA
        • Osman MN
        • et al.
        Simultaneous venoarterial extracorporeal membrane oxygenation and percutaneous left ventricular decompression therapy with Impella is associated with improved outcomes in refractory cardiogenic shock.
        ASAIO J. 2019; 65: 21-28
        • Cho Y
        • Wakasa S
        • Usui A
        • Minatoya K
        • Arai H
        • Yaku H
        • Yamaguchi A
        • Komiya T
        • Matsumiya G
        • Hamano K
        • Saiki Y
        • Matsui Y.
        Non-heart transplant surgical approaches with mitral valve operation and surgical ventricular reconstruction for non-ischaemic dilated cardiomyopathy: a Japanese multicenter study.
        Gen Thorac Cardiovasc Surg. 2021; 69: 679-689
        • Tanaka D
        • Hirose H
        • Cavarocchi N
        • Entwistle JWC.
        The impact of vascular complications on survival of patients on venoarterial extracorporeal membrane oxygenation.
        Ann Thorac Surg. 2016; 101: 1729-1734
        • Dhruva SS
        • Ross JS
        • Mortazavi BJ
        • Hurley NC
        • Krumholz HM
        • Curtis JP
        • Berkowitz A
        • Masoudi FA
        • Messenger JC
        • Parzynski CS
        • Ngufor C
        • Girotra S
        • Amin AP
        • Shah ND
        • Desai NR.
        Association of use of an intravascular microaxial left ventricular assist device vs intra-aortic balloon pump with in-hospital mortality and major bleeding among patients with acute myocardial infarction complicated by cardiogenic shock.
        JAMA. 2020; 323: 734-745
        • Davis ME
        • Haglund NA
        • Tricarico NM
        • Keebler ME
        Maltais S. Development of acquired von Willebrand syndrome during short-term micro axial pump support: implications for bleeding in a patient bridged to a long-term continuous-flow left ventricular assist device.
        ASAIO J. 2014; 60: 355-357
        • Flierl U
        • Tongers J
        • Berliner D
        • Sieweke JT
        • Zauner F
        • Wingert C
        • Riehle C
        • Bauersachs J
        • Schäfer A.
        Acquired von Willebrand syndrome in cardiogenic shock patients on mechanical circulatory microaxial pump support.
        PLoS One. 2017; 12e0183193
        • Al Saadi T
        • Andrade A
        • Chickerillo K
        • Joshi A
        • Sciamanna C
        • Pauwaa S
        • Macaluso G
        • Dia M
        • Cotts W
        • Tatooles A
        • Pappas P
        A case series of patients with left ventricular assist devices and concomitant mechanical heart valves.
        Artif Organs. 2020; 44: 1050-1054