Successful Lysis of Thrombus with Tissue Plasminogen Activator in a Bidirectional Glenn on Venoarterial Extracorporeal Life Support

This case report describes a 7 kg male with double inlet right ventricle, transposition of the great arteries and pulmonary atresia admitted to Stollery Children’s Hospital, Edmonton, Alberta for bidirectional Glenn (BDG) and patch augmentation of the left pulmonary artery (LPA). The patient had undergone three previous operations, initially a right modified Blalock-Taussig shunt (3.5mm), followed by several attempts to recruit the LPA by bovine pericardial patch. He was palliated with a BDG and LPA autologous pericardial patch. The LPA thrombosed accepts for its intraparenchymal portion. Given the presence of ongoing hypoplasia and acute thrombosis of the LPA, the decision was made to place a central shunt with the aim of securing pulmonary blood flow to the left lung and augmenting growth of peripheral vasculature. A 4.0 mm Gore-Tex central shunt from the ascending aorta to LPA was placed which subsequently thrombosed. The child proceeded to develop both chylothorax and mediastinitis. A peripherally inserted central cannula (PICC) was placed in the right arm with the tip in the SVC for total parenteral nutrition and antibiotics. Forty-eight hours post mediastinal washout, the patient became acutely hypoxemic and had a cardiopulmonary arrest. Although return of spontaneous circulation was restablished, the patient was cannulated centrally (right atrium and ascending aorta) for VA ECLS for hyperlactatemia. The ECLS run was complicated by circuit thrombosis despite therapeutic anti-Xa levels. Confirmatory testing for heparin-induced thrombocytopenia by lumi-aggregometry was negative. He was decanulated after 43 hours, however two days later the patient thrombosed his BDG circulation and required repeat central ECLS cannulation for hypoxemia.