four months before , the patient had developed cardiogenic shock while attempting stent insertion ( endeavor 3.0~18 ) into the obstructed left main coronary artery ( 80% ) , which necessitated urgent institution of extracorporeal membrane oxygenation ( ecmo ) and intra - aortic balloon pump . after coming off extracorporeal life support systems
, she underwent stenting ( taxus 2.75~38 ) of the obstructive left anterior descending coronary artery ( lad ) , which resulted in second attack of cardiogenic shock and ecmo support , which was successfully weaned off .
she had been discharged home after these events , and had been followed up in the outpatient department . on arrival at er , her consciousness was clear , and chest x - ray showed pulmonary congestion .
on echocardiography , severe mitral regurgitation due to restricted valve motion was noted , and left ventricular ejection fraction was 28% .
she developed the third attack of cardiogenic shock during emergency coronary angiogram , and was put on ecmo again ( fig .
1 ) . coronary angiogram on ecmo support showed restenosis of the previous lad stent ( 80% ) and complete obstruction of the left circumflex and right coronary arteries .
after ecmo circuit was converted to conventional cardiopulmonary bypass using the same femoral artery - vein cannulae , a great saphenous vein graft was anastomosed to the lad and an additional saphenous vein graft was placed from the lad graft to the posterior descending coronary artery in an inverted - y fashion .
operative findings of the mitral valve consisted of severe fibrotic change of the anterior leaflet , dilatation of the mitral valve annulus , and central non - coaptation .
the patient was able to come off bypass without any event . cardiopulmonary bypass time and aortic cross - clamping time were 168 minutes and 85 minutes , respectively .
in provision for the later postoperative use , we decided to leave the femoral arterial and venous cannulae in situ , which were removed on postoperative day 1 .
she was extubated on postoperative day 4 , but developed superficial wound infection with dehiscence which was repair on postoperative day 36 .
she was readmitted in 2 months after discharge due to general weakness , fever , and septicemia .
echocardiography showed 73 mm sized vegetation at the prosthetic mitral valve , and bacteriologic examination identified methicillin - resistant staphylococcus aureus as a causative microorganism .
surgical intervention was recommended , but the patient refused to receive further treatment and died of sepsis .
he had a smoking history of 10 pack - years , and had been followed up in the out - patient clinic for systemic hypertension , myocardial infarction and moderate mitral regurgitation .
four months before , he had undergone coronary artery stenting ( cypher 3.0~33 ) to relieve complete obstruction of lad , which resulted in the deterioration of mitral regurgitation .
echocardiography at this admission revealed severe mitral regurgitation due to restricted valve motion , and left ventricular ejection fraction was 30% . upon coronary angiography
x ray and moderate left ventricular dysfunction , we elected to put the patient on ecmo temporarily to ameliorte cardiopulmonary function .
after 2 days of ecmo support , the patient was brought to the operating room and cardiopulmonary bypass was instituted using the same femoral arterial and venous cannulae .
an additional venous cannula was inserted into the superior caval vein after sternotomy due to insufficient venous drainage from the single femoral venous cannula .
operative findings of the mitral valve were annular dilatation and restrictive motion of the posterior leaflet .
ring annuloplasty using commercialized mitral ring ( carpentier - edwards physio ring 28 mm , edwards ) was performed .
the patient came off cardiopulmonary bypass without any event , and , differing from the 1st case , the femoral arterial and venous cannulae were removed after the completion of the procedures .
intra - operative trans - esophageal echocardiography showed mild residual mitral regurgitation . cardiopulmonary bypass time and aortic cross - clamping time were 103 minutes and 53 minutes , respectively .
the patient was extubated on postoperative day 1 , and echocardiography on postoperative day 19 showed mild to moderate residual mitral regurgitation .
he was discharged home on postoperative day 29 , and has been followed up for 14 months in a good clinical condition .
four months before , the patient had developed cardiogenic shock while attempting stent insertion ( endeavor 3.0~18 ) into the obstructed left main coronary artery ( 80% ) , which necessitated urgent institution of extracorporeal membrane oxygenation ( ecmo ) and intra - aortic balloon pump . after coming off extracorporeal life support systems
, she underwent stenting ( taxus 2.75~38 ) of the obstructive left anterior descending coronary artery ( lad ) , which resulted in second attack of cardiogenic shock and ecmo support , which was successfully weaned off .
she had been discharged home after these events , and had been followed up in the outpatient department . on arrival at er , her consciousness was clear , and chest x - ray showed pulmonary congestion .
on echocardiography , severe mitral regurgitation due to restricted valve motion was noted , and left ventricular ejection fraction was 28% .
she developed the third attack of cardiogenic shock during emergency coronary angiogram , and was put on ecmo again ( fig .
1 ) . coronary angiogram on ecmo support showed restenosis of the previous lad stent ( 80% ) and complete obstruction of the left circumflex and right coronary arteries .
after ecmo circuit was converted to conventional cardiopulmonary bypass using the same femoral artery - vein cannulae , a great saphenous vein graft was anastomosed to the lad and an additional saphenous vein graft was placed from the lad graft to the posterior descending coronary artery in an inverted - y fashion .
operative findings of the mitral valve consisted of severe fibrotic change of the anterior leaflet , dilatation of the mitral valve annulus , and central non - coaptation .
the patient was able to come off bypass without any event . cardiopulmonary bypass time and aortic cross - clamping time were 168 minutes and 85 minutes , respectively .
in provision for the later postoperative use , we decided to leave the femoral arterial and venous cannulae in situ , which were removed on postoperative day 1 .
she was extubated on postoperative day 4 , but developed superficial wound infection with dehiscence which was repair on postoperative day 36 .
she was readmitted in 2 months after discharge due to general weakness , fever , and septicemia .
echocardiography showed 73 mm sized vegetation at the prosthetic mitral valve , and bacteriologic examination identified methicillin - resistant staphylococcus aureus as a causative microorganism .
surgical intervention was recommended , but the patient refused to receive further treatment and died of sepsis .
he had a smoking history of 10 pack - years , and had been followed up in the out - patient clinic for systemic hypertension , myocardial infarction and moderate mitral regurgitation .
four months before , he had undergone coronary artery stenting ( cypher 3.0~33 ) to relieve complete obstruction of lad , which resulted in the deterioration of mitral regurgitation .
echocardiography at this admission revealed severe mitral regurgitation due to restricted valve motion , and left ventricular ejection fraction was 30% . upon coronary angiography
x ray and moderate left ventricular dysfunction , we elected to put the patient on ecmo temporarily to ameliorte cardiopulmonary function .
after 2 days of ecmo support , the patient was brought to the operating room and cardiopulmonary bypass was instituted using the same femoral arterial and venous cannulae .
an additional venous cannula was inserted into the superior caval vein after sternotomy due to insufficient venous drainage from the single femoral venous cannula .
operative findings of the mitral valve were annular dilatation and restrictive motion of the posterior leaflet .
ring annuloplasty using commercialized mitral ring ( carpentier - edwards physio ring 28 mm , edwards ) was performed .
the patient came off cardiopulmonary bypass without any event , and , differing from the 1st case , the femoral arterial and venous cannulae were removed after the completion of the procedures .
intra - operative trans - esophageal echocardiography showed mild residual mitral regurgitation . cardiopulmonary bypass time and aortic cross - clamping time were 103 minutes and 53 minutes , respectively .
the patient was extubated on postoperative day 1 , and echocardiography on postoperative day 19 showed mild to moderate residual mitral regurgitation .
he was discharged home on postoperative day 29 , and has been followed up for 14 months in a good clinical condition .
coronary artery disease is frequently associated with mitral regurgitation . as benefits are substantiated by the meta - analysis of the reports pertaining to the outcome of surgical intervention on ischemic mitral regurgitation ,
concomitant mitral valve surgery upon coronary artery bypass grafting is recommended by the major academic bodies in north america ( i.e. american college of cardiology , american heart association ) and in europe ( i.e. european society of cardiology ) .
elimination of the left ventricular volume overloading by mitral valve surgery is believed to be beneficial for the recovery of left ventricular function after coronary artery revascularization . with respect to the types of mitral valve surgery
, either mitral valve replacement or mitral annuloplasty could be performed according to the disposition of valve pathology and patient characteristics .
for instance , valve replacement is recommended in case of papillary muscle rupture or leaflet motion restriction caused by papillary muscle displacement .
there are a number of reports asserting the superiority of the mitral valve repair over replacement , but selection from the two surgical options should be undertaken based on the exact valve regurgitation mechanism of individual patients . in this report ,
the first patient underwent valve replacement due to the severe fibrotic change of the anterior leaflet , while ring annuloplasty alone was deemed appropriate to alleviate severe mitral regurgitation in the second case .
as for the selection of the life support system , intra - aortic balloon pump ( iabp ) has been widely used as a rescue measure for circulatory collapse .
iabp is believed to improve left ventricular function by reducing left ventricular afterload and augmenting coronary perfusion while maintaining pulsatility of the systemic circulation
. however , barlett et al .   claimed that ecmo is more beneficial for cardiogenic shock , given that patients in this setting may need both circulatory and pulmonary support . in between these two assertions ,
proposed that iabp is indicated for patients with coronary artery disease while ecmo is preferred in patients with valvular heart diseases . in our first case ,
ecmo was used because coronary arteries were severely obstructed and iabp alone might have not been effective . in the second case ,
indications for ecmo or other percutaneous circulatory support systems are diverse , such as cardiac arrest , cardiogenic shock , high - risk cardiovascular intervention , bridge to emergency cardiac operation or cardiac transplantation , and pulmonary thromboembolism [ 6 - 10 ] .
conducted a meta - analysis of 85 publications between 1966 and 2005 regarding percutaneous cardiopulmonary bypass , and concluded that this measure is mostly effective for rescuing critically ill patients , providing the median survival of 47% in 1,495 patients enrolled in this analysis . in the literature , however , survival rate after instituting mechanical circulatory support widely varies between 15% and 60% , which may well be attributed to small number of patients in most of the reports , diversity of the underlying diseases , and differences in experience and quality of care from one institution to another .
it has been reported that selection of candidates , timing of life support system installation and technical aspects mainly determine the survival .
mechanical circulatory support may be mandatory upon coronary angiography or catheter intervention in high - risk patients with cardiogenic shock or uncontrolled arrhythmia .
reported that mechanical circulatory support was necessary in 275 ( 15.4% ) among 1,785 patients who underwent cardiovascular intervention for acute myocardial infarction .
with respect to the institution of life support system as a bridge to a definitive cardiac operation , there are reports of successful cardiac operation after an urgent installation of mechanical circulatory support for cardiogenic shock which developed during coronary angiography .
grambow et al .   reported 20% survival in patients with circulator assist device instituted for circulatory collapse in the catheterization laboratory .
for the percutaneous circulatory support , we are using capiox emergency bypass system ( ebs ; terumo inc , tokyo , japan ) , which consists of centrifugal pump , membrane oxygenator ( polypropylene hollow fiber ) and heparin - coated circuit .
this system is characterized by lower heparin administration , longer durability of the oxygenator , fast and easy auto - priming , and small - sized equipment with excellent adaptability to a small space .
thus , we have an institutional strategy to institute ebs system as soon as possible in case of cardiogenic shock after coronary artery angiography or intervention , and this might have lead to rescue the two patients with cardiogenic shock in the catheterization laboratory .
 indication for extracorporeal membrane oxygenation ( ecmo ) has been extended as the experience of ecmo in various clinical settings accumulates and the outcome after ecmo installation improves . 
 we report two cases of successful mitral valve surgery for severe ischemic mitral regurgitation in patients on ecmo support for cardiogenic shock which developed upon coronary angiography . 
CASE REPORT
1) Case 1
2) Case 2
DISCUSSION