case_images: PMC10978710_01
case_images: A cross-sectional CT scan performed upon arrival to the emergency department that rules out pulmonary embolism and shows bilateral interstitial consolidations consistent with pulmonary edema.
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case_images: PMC10978710_01_fcvm-11-1345654-g001.jpg
case_images: F1
case_images: A computed tomography (CT) scan was performed, which showed diffuse pulmonary edema but ruled out pulmonary embolism (Figure 1).
case_images: A transesophageal echocardiogram performed during VA ECMO cannulation and Impella placement showing severe mitral regurgitation with the central jet and a thickening of the mitral valve leaflets.
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case_images: PMC10978710_01_fcvm-11-1345654-g002.jpg
case_images: F2
case_images: The mitral regurgitation was described as "severe" and the findings were consistent with endocarditis and papillary muscle rupture (Figure 2).
case_images: An ECMO configuration after combining VV and VA ECMO using a single pump and oxygenator with oxygenated blood delivered to both the pulmonary and the systemic circulations. The use of the Hoffman clamps allowed for titration of flow through both systems without the complications associated with two competing pumps. The flow measurement controller on the arterial side of the VV circuit was used only as a flow-measuring device and RPMs were not titrated.
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case_images: PMC10978710_01_fcvm-11-1345654-g003.jpg
case_images: F3
case_images: Considering the patient's need for nitric oxide, the evidence of pulmonary edema and fibrosis noted on the initial CT scan, and the concern for prolonged pulmonary support after myocardial recovery, a decision was made to incorporate a VV ECMO circuit into the existing VA ECMO circuit (Figure 3).
case_images: A cross-sectional CT scan obtained for a 3-month follow-up showing minimal basilar scarring with complete resolution of the previously noted edema. More inferior images show a well-placed mitral prosthesis and a well-approximated sternum.
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case_images: PMC10978710_01_fcvm-11-1345654-g004.jpg
case_images: F4
case_images: Follow-up testing showed adequate pulmonary recovery both radiographically and on pulmonary function tests (Figure 4).