CARD14: Shifting Surgical Archetypes Of ICG Fluorescent-Angiography For Bowel Perfusion Assessment In Cardiogenic Shock on ECMO Support

Background: Acute extracorporeal membrane oxygenation (ECMO) has been adopted to support patients with acute severe cardiac or pulmonary failure that is unresposive to conventional management and potentially reversible. Parallel to this, in the presence of pulmonary embolism, mesenteric ischemia (MI) might prsent as a life-threatening disorder. Due to the nature and acuity of these diseases, determining adequate perfusion upon surgical intervention is challenging for the operating surgeon, especially in the presence of cardiogenic shock despite ECMO support. Indocyanine green fluorescent angiography (ICG-FA) has proven to be useful for real-time vascular perfusion assessment, which may potentially decrease the rate of development of perfusion-related complications. The purpose of this case report is to showcase the possibility of performing noncardiac surgical procedures (NCSPs) in critical cardiac care patients under extracorporeal life support. Methods: A 61-year-old male initially presented to the emergency department with a 4 day history of right upper quadrant abdominal pain, weakness, fatigue, and dyspnea. Initial workup identified the presence of acute cholecystitis, right sided pleural effusion and a pulmonary embolism in transit in the right atrium. An emergent pulmonary embolectomy was performed requiring subsequent venoarterial (VA) ECMO support due to severe right ventricular failure. The postoperative course was complicated with the acute onset of MI requiring the performance of an exploratory laparotomy, subtotal colectomy, small bowel resection, ileostomy, and cholecystectomy, all under ECMO support. To ensure preservation of end-organ perfusion, ICG-FA was performed in a trans-operative fashion to assess bowel perfusion and presence of ischemia, and determine salvage of viable segments. Results: Upon performance of the exploratory laparotomy, ICG-FA allowed for proper recognition of ischemic and grossly viable bowel segments, overall facilitating the performance of the intestinal resection and consequent ileostomy. The patient tolerated all abdominal procedures well under ECMO support and continued resuscitation in the intensive care unit. Conclusions: ICG-FA is a safe, costly-effective, useful visual aid tool for the real-time assessment of end-organ perfusion. The case report presented breaks the paradigm of performing NCSPs on ELS. Further larger prospective studies are needed to draw comprehensive conclusions from this initial premise.