We present the first documented case of emergent pericardial drainage and return (PD-R) under extracorporeal membrane oxygenation (ECMO) for the management of aortic rupture into the pericardial sac caused by acute type A aortic dissection (AADA). An 83-year-old woman collapsed during an elective coronary intervention. ECMO was eventually required. Acute accumulation of pericardial effusion with aortic dissection was revealed by echocardiography. Percutaneous pericardial drainage was performed using a drainage line connected to the venous line of the ECMO system to maintain blood flow and blood pressure. After stabilization of the patient’s hemodynamics, immediate aortic repair was successfully performed and the patient was discharged with no neurological deficit. In cases of massive amounts of pericardial drainage and persistent hemorrhagic shock due to aortic rupture with AADA, PD-R connected to ECMO is useful while waiting for aortic repair.

Pericardial drainage (PD) is generally required for treatment of patients with cardiac tamponade due to aortic rupture. Controlled pericardial drainage (CPD), in which elevation of blood pressure is prevented by adjusting the amount of drained fluid, has been recognized as a favorable procedure for critical cardiac tamponade with acute type A aortic dissection (AADA) [1-3]. However, in cases of massive accumulation of pericardial effusion because of aortic rupture, CPD is not sufficient to maintain blood pressure. Here, we report that PD and return (PD-R) connected to extracorporeal membrane oxygenation (ECMO) was effective for the management of cardiac tamponade and hemorrhagic shock due to aortic rupture with AADA.

An 83-year-old woman with a history of cerebral infarction was hospitalized with a diagnosis of stenosis in the left anterior descending branch. An elective percutaneous coronary intervention was started using a right radial artery approach; however, catheter engagement was difficult because of the tortuosity of the brachiocephalic artery and ascending aorta. She complained of chest pain, followed by loss of spontaneous respiration and palpable pulsations; therefore, cardiopulmonary resuscitation (CPR) was immediately initiated. Because she did not recover, despite continued CPR, ECMO via the right femoral artery and left femoral vein was started. The time from collapse to the induction of ECMO was 11 min.

Subsequently, tracheal intubation was performed, followed by the appearance of cyanosis of the face and distension of the jugular veins. Transthoracic echocardiography revealed the rapid accumulation of pericardial fluid and aortic dissection in the ascending aorta. The patient then underwent CPD for drainage of bloody fluid. However, because it decreased the circulating blood volume and worsened concomitant hemorrhagic shock, her blood pressure and the blood flow during ECMO remained unstable. Then, the drainage route was directly connected to the venous line of the ECMO system, resulting in a flow rate of 2–2.5 L/min (Fig. 1). The hemodynamic state was stabilized by adjusting the ECMO flow via control of the drainage volume of the pericardial effusion, which led to rapid improvement of the cyanosis of her face and the distension of the jugular veins.

Fig. 1.

Controlled pericardial drainage-return connected to an extracorporeal membrane oxygenation (ECMO) system. Pericardial drainage (red arrow) and connection between a pericardial drainage catheter and the ECMO catheter (red circle).

Fig. 1.

Controlled pericardial drainage-return connected to an extracorporeal membrane oxygenation (ECMO) system. Pericardial drainage (red arrow) and connection between a pericardial drainage catheter and the ECMO catheter (red circle).

Close modal

Subsequently, computed tomography was performed, which resulted in a diagnosis of AADA with rupture of the ascending aorta (Fig. 2). The patient was transferred to the operating room, with a time from onset to operation of 92 min. The intraoperative findings confirmed the presence of aortic dissection and rupture in the ascending aorta, with an initial tear near the orifice of the left coronary artery and an adventitial tear in the left sinus of Valsalva. Reconstruction of the left sinus of Valsalva and ascending aorta and coronary artery bypass grafting from the aorta to the left anterior descending branch using the saphenous vein graft were performed. The postoperative course was uneventful. The patient had no neurological deficit and was transferred to a rehabilitation hospital 45 days after surgery.

Fig. 2.

a Enhanced computed tomography (CT) image showing dissection of the ascending aorta with pericardial effusion. b Enhanced CT image showing the pericardial effusion and a drainage catheter (red circle).

Fig. 2.

a Enhanced computed tomography (CT) image showing dissection of the ascending aorta with pericardial effusion. b Enhanced CT image showing the pericardial effusion and a drainage catheter (red circle).

Close modal

Cardiac tamponade, including aortic rupture into the pericardial sac, is one of the most problematic complications of AADA; it can cause rapid deterioration of the hemodynamic state and may result in shock and cardiopulmonary arrest. Among the complications of AADA, cardiopulmonary arrest caused by cardiac tamponade has the worst outcome [4-6]. Pericardial drainage for AADA management has been abandoned, and drainage should be considered only when it is difficult to maintain hemodynamics by the start of surgery [7]. However, we previously reported favorable results of CPD in the prevention of elevation of blood pressure while adjusting the amount of drained fluid [1, 2]. Moreover, CPD was evaluated as class IIa in the guidelines of the European Society of Cardiology [8].

We recently reported the efficacy of CPD and return (CPD-R), in which the drained bloody fluid is returned directly to the venous line for increasing the circulating blood volume simultaneously with drainage in some cases [9]. However, in cases of massive accumulation of pericardial effusion because of aortic rupture into the pericardial sac, CPD is not sufficient to maintain blood pressure. In the case reported here, although ECMO was initiated for CPR and CPD was performed, the hemodynamic state of the patient remained unstable until the drainage line was directly connected to the venous line of the ECMO system.

The advantages of the combined use of PD-R and ECMO included the maintenance of hemodynamics by draining the amount of bloody pericardial effusion, the maintenance of ECMO flow, and the rapid reduction of central venous pressure, which may increase perfusion of the brain. One limitation of this method is the possibility of aeration in the ECMO circuit. We prevented aeration with careful deairing with a one-way valve. In addition, because the drainage route was directly connected to the venous line of the ECMO system, air embolism was less likely to occur due to capture of the centrifugal blood pump or gas exchange devices. Another limitation is that there may be a risk of applying a too high negative pressure to the drainage tube. However, measuring the inner pressure of the drainage tube is impossible in the urgent situation. We think that there can be no other way to check high negative pressure than by verifying resistance while aspirating pericardial fluid with a syringe.

This report demonstrates the usefulness of PD-R connected to an ECMO system for patients with a massive amount of pericardial drainage and hemorrhagic shock complicated by AADA. PD-R connected to an ECMO system is useful while waiting for aortic repair in this patient cohort.

In cases with a massive amount of pericardial drainage and sustained hemorrhagic shock, PD-R connected to an ECMO system is useful for the management of critical cardiac tamponade caused by AADA.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

The authors have no conflicts of interest to declare.

The authors did not receive any financial support.

S. Ijuin was involved in main work, data collection, and manuscript writing. M.T., C.N., A.I., S. Izumi, N.I., S.M., S. Ishihara, T.D., and S.N. were involved in data collection and manuscript revision. T. Tsukube was involved in final revision.

1.
Hayashi
T
,
Tsukube
T
,
Yamashita
T
,
Haraguchi
T
,
Matsukawa
R
,
Kozawa
S
, et al
Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection
.
Circulation
.
2012
Sep
;
126
(
11
Suppl 1
):
S97
101
.
[PubMed]
0009-7322
2.
Nakai
C
,
Izumi
S
,
Haraguchi
T
,
Okada
Y
,
Ijuin
S
,
Nakayama
S
, et al
Long-term outcomes following controlled pericardial drainage for acute type A aortic dissection
.
Ann Thorac Surg
.
2020
Oct
;
110
(
4
):
1357
63
.
[PubMed]
0003-4975
3.
Honda
M
,
Okamura
H
,
Inoue
T
,
Maekawa
T
. Avoidance of obstructive shock in patients with acute A type aortic dissection treated by emergency pericardial drainage. J Japanese association of acute medicine.
2017
; 28:55-8.
4.
Gilon
D
,
Mehta
RH
,
Oh
JK
,
Januzzi
JL
 Jr
,
Bossone
E
,
Cooper
JV
, et al;
International Registry of Acute Aortic Dissection Group
.
Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection
.
Am J Cardiol
.
2009
Apr
;
103
(
7
):
1029
31
.
[PubMed]
0002-9149
5.
Bayegan
K
,
Domanovits
H
,
Schillinger
M
,
Ehrlich
M
,
Sodeck
G
,
Laggner
AN
.
Acute type A aortic dissection: the prognostic impact of preoperative cardiac tamponade
.
Eur J Cardiothorac Surg
.
2001
Dec
;
20
(
6
):
1194
8
.
[PubMed]
1010-7940
6.
Murai
,
T.
Aortic Dissection and Sudden Death -Statistical Analysis on 1320 Cases Autopsied at Tokyo-to Medical Examiner Office. Japanese journal of legal medicine.
1988
:42(6) 564-77
7.
Hiratzka
LF
,
Bakris
GL
,
Beckman
JA
,
Bersin
RM
,
Carr
VF
,
Casey
DE
 Jr
, et al;
American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
;
American Association for Thoracic Surgery
;
American College of Radiology
;
American Stroke Association
;
Society of Cardiovascular Anesthesiologists
;
Society for Cardiovascular Angiography and Interventions
;
Society of Interventional Radiology
;
Society of Thoracic Surgeons
;
Society for Vascular Medicine
.
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology
.
Circulation
.
2010
Apr
;
121
(
13
):
e266
369
.
[PubMed]
1524-4539
8.
Adler
Y
,
Charron
P
,
Imazio
M
,
Badano
L
,
Barón-Esquivias
G
,
Bogaert
J
, et al;
ESC Scientific Document Group
.
2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS)
.
Eur Heart J
.
2015
Nov
;
36
(
42
):
2921
64
.
[PubMed]
0195-668X
9.
Ijuin
S
,
Ishihara
S
,
Haraguchi
T
,
Matsuyama
S
,
Nakayama
S
,
Tsukube
T
, et al
Efficacy of controlled pericardial drainage return for cardiac tamponade with acute type A aortic dissection. J Japanese association of acute medicine.
2020
; 31:227-32
Open Access License / Drug Dosage / Disclaimer
This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.