Changing Strategies to Avoid Extracorporeal Circulation in Severe Left Heart Failure after Neonatal Myocardial Infarction: A Case Report

Background: Neonatal myocardial infarction is rare and associated with high mortality. Treatment strategies often include extracorporeal circulation as a bridge to recovery or transplant. This is associated with severe complications, especially due to long organ waiting periods in this vulnerable age group.

Methods: We herein report the case of a neonate with concomitant apical VSDs who presented with severe left heart failure immediately after birth. Laboratory and echocardiographic findings were suspicious of myocardial infarction. Coronary angiography confirmed a thrombus in the left coronary artery. Local and systemic thrombolysis was applied. Inotropic therapy was initiated to secure sufficient cardiac output and prostaglandin E1 was started to maintain ductal patency. Weaning efforts from prostaglandin led to clinical and echocardiographic deterioration. Therefore, as a bridge to possible recovery or transplantation, a hybrid treatment involving stenting of the arterial duct and bilateral pulmonary banding was performed on day nine of life to maintain fetal circulation and prevent pulmonary overload. The patient consequently stabilized, but left heart function remained severely impaired. Thus, the patient was listed for heart transplantation. Due to decreasing pulmonary vascular resistance, shunting over the ventricular septal defects and the arterial duct led to pulmonary volume overload with recurring respiratory decompensation. The hybrid was taken down at an age of 3½ months. Instead, a central pulmonary banding was performed not only to limit shunt volume but also as an attempt to improve left ventricular function via ventricular-ventricular interaction. Remarkably, cardiac output could then sufficiently be maintained by the left ventricle with inotropic support, yet weaning of Milrinone was still not viable. Left atrial congestion with a restrictive atrial septal defect required multiple catheter interventions. Eventually, the patient received a successful heart transplant without perioperative complications after a waiting time of ten months. Follow up so far is uneventful.

Conclusion: The presented case highlights the changeability in pediatric hemodynamics and the necessity to adjust therapeutic strategies to maintain sufficient cardiac output. Avoiding extracorporeal circulation in neonatal heart failure is crucial to reduce morbidity and mortality.

Publication History

Article published online:
13 February 2024