Discussion

The ICG-FA technology serves as a trans-operative tool for real-time perfusion evaluation in multiple procedures, providing visual feedback for the improvement of clinical decision-making, especially in high morbidity and mortality cases. Acute MI continues to be a life-threatening condition with mortality rates comparable to CS [1,5]. Owing to the nature of these, evaluation of bowel vitality and cardiac stability is critical for successful outcomes when performing a surgical approach. The clinical decision-making based on surgeons’ clinical judgment has low sensitivity and specificity for all kinds of anastomosis [6]. Adequate surgical navigation is a culprit for successful surgical intervention in the presence of MI, and so is the ability to diagnose accompanying conditions that may preclude operative outcomes.
This case conveys multiple conditions that further extend the mortality risk of the patient. However, the resolution of the patient’s PE, subsequent RV failure and MI, and ensuing CS, shifted priorities. While pulmonary embolectomy, RV failure and CS have been described as a cascade of cardiac complications, this case stands out due to the ELS provided to address NCSPs. In a recent study examining NCSPs in patients on ECMO, after logistic regression analysis, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68–1.23, p = 0.17) [7].
This case report challenges the paradigm of no-intervention in the setting of ELS. After multidisciplinary discussions, abdominal surgery was performed despite VA-ECMO support. The benefits overweighed the risks because of the ultimate objective to correctly preserve tissue with the potential to recover. As it is well known, perfusion at the site of resection/anastomosis is challenging to evaluate. While models of prediction of intestinal viability using subjective clinical criteria have been reported, 57% accuracy is underwhelming [8]. Conversely, trans-operative perfusion assessment techniques via ICG-FA have reported multiple satisfactory outcomes, including the detection of necrotic intestinal segments otherwise non-discernable by the naked eye, and the improved outcomes of acute MI cases when implementing ICG-FA as part of protocol intervention. A larger study determined the applicability of ICG-FA to reduce extended bowel resections in acute MI by leading to major changes in operative strategy and better clinical outcomes [9]. Parallelly, ICG-FA has assessed bowel perfusion during laparoscopic colorectal resection, eliminating the presence of postoperative leaks and reducing mortality rates [10].
While the dosing, approach, indications, presence of comorbidities vary, a standardized clinical guideline has yet to be placed in order to serve as a navigational course when considering ICG-FA. While our patient ultimately succumbed, the NCSPs performed safely with outstanding preservation of viable gastrointestinal segments and cardiac stability. It is important to highlight that the patient presented with a superimposed high mortality risk (primary PE, irreversible RV, acute MI, and CS). The main purpose of this case report is to propose the consideration of performing NCSPs even in critical cardiac condition patients.
This case report’s strength holds sound in the pioneering venture of safely performing NCSPs under ELS. The weaknesses are directed towards the relative novelty of the application of this technique and its lack of standardized societal clinical guidelines. Our experience with ICG-FA is based on time to peak intensity and dose dependent, regardless of ELS. Thus, although visual aid was achieved, a level of subjectivity accompanies the clinical decision-making of the resection/anastomotic approach. Whether these variables have a true effect on the adequacy of the perfusion evaluation, its preservation and absence of leak was still achieved. More so, ICG-FA models have yet to determine the precise and optimal blood flow rate needed to ensure tissue salvage/preservation. Previous efforts to assess blood supply have yet to define the optimal blood flow needed to avoid anastomotic leakage [10]. Finally, ICG has limits to take into account: Limited penetrance of 10 mm in target tissues, short vascular clearance of 3-4 minutes, and a relative dependency on albumin bonds [4]. These become relevant, especially in the presence of multiorgan failure from a secondary CS, consequent of a primary PE, further complicated by acute MI.