ID:136 FC-D09-7 The Novel Technique of Damage Control Thoracotomy for Fatal Intrathoracic Hemorrhage in a Patient with ECPELLA

Background: Damage control thoracotomy, performed by open chest with temporary chest closure (TCC), has been considered effective in trauma patients with fatal intrathoracic hemorrhage. However, intrathoracic gauze packing must balance the effective hemostasis with reduction of total lung capacity and cardiac output. We report a case of fatal intrathoracic hemorrhage who was managed using a novel TCC technique during ECPELLA management. Clinical Course: A 51-year-old man underwent elective clamshell thoracotomy to resect a large anterior mediastinal carcinoid tumor. Following tumor resection, he experienced refractory ventricular fibrillation and necessitated ECPR. While the etiology of cardiac arrest was unknown, ECPELLA was initiated followed by chest closure. However, as intrathoracic bleeding persisted on the next day, thoracotomy was re-performed and intrathoracic packing with TCC, using negative pressure wound therapy, was conducted to control diffuse hemorrhage at the surgical site. Gauze was packed around the hilum and in the anterior mediastinum that compressed the right lung and right ventricle. Respiration and circulation were maintained by ECPELLA for 3 days with stable ECPELLA flow, and the gauze was removed followed by definitive chest closure. Pulse pressure and minute ventilation significantly increased after the gauze removal, and ECPELLA was successfully weaned on postoperative day 7. The patient was discharged ambulatory on postoperative day 36. Discussion: The damage control thoracotomy by open chest with TCC during ECMO would necessitate appropriate collaboration between trauma surgeons and ECMO physicians. To obtain better outcomes, surgical strategy and extracorporeal managements need to be adjusted based on patient status. Conclusion: We experienced a case of ECPELLA in which fatal intrathoracic hemorrhage was successfully managed with novel technique of damage control thoracotomy.