Successful management of severe liver failure on venoarterial extracorporeal membrane oxygenation using molecular adsorbent recirculating systeme.

Abstract

A 49-year-old female with Adriamycin induced cardiomyopathy presented with decompensated biventricular congestive heart failure. Despite multiple Inotropes, the patient’s hemodynamics deteriorated and she underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) placement as a bridge to decision. Pre-ECMO workup showed liver dysfunction with elevated total bilirubin of 5.9 mg/dl, normal liver enzymes and liver ultrasound image. Tentative diagnosis of “end-stage liver failure” was made without a biopsy. Shortly after initiation of ECMO, the patient developed massive hemoptysis which was successfully managed with continuation of ECMO and ventilator management. [i] The patient’s total bilirubin continued to increase to peak of 56 mg/dl on ECMO day #9 (Figure 1). Molecular adsorbent recirculating system (MARS) was initiated on ECMO day 9 thru 14. The bilirubin improved dramatically with MARS. Liver biopsy performed while on ECMO provided a definitive diagnosis of cholestasis without cirrhosis. The patient underwent Heart Mate II left ventricular assist device (LVAD) placement and ECMO removal on ECMO day 20. There was no further episode of liver failure, and the patient was eventually discharged from hospital. [i] Harrison M, Cowan S, Cavarocchi N, Hirose H. Massive hemoptysis on veno-arterial extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 2012 Mar 30. [Epub ahead of print]