12: Successful Performance of Urgent Gynecologic Surgery During VA-ECMO Support in a Post-CABG Patient: A Case Report.

Background: Major noncardiac surgery in patients supported by venoarterial extracorporeal membrane oxygenation (VA-ECMO) is rare and technically complex due to altered physiology, anticoagulation requirements, and the need for close multidisciplinary coordination. We present a case highlighting the feasibility and challenges of emergent gynecologic surgery in a patient supported by VA-ECMO following cardiac surgery. Case Presentation: A 52-year-old woman with ischemic heart disease, diabetes mellitus, asthma, and chronic kidney disease underwent urgent coronary artery bypass grafting. Her postoperative course was complicated by cardiogenic shock and respiratory failure, requiring initiation of VA-ECMO on postoperative day three via femorofemoral cannulation. Imaging subsequently revealed a hemorrhagic uterine fibroid causing significant mass effect and recurrent bleeding, necessitating urgent surgical intervention. A multidisciplinary team involving cardiac anesthesia, gynecology, ECMO perfusion, and intensive care planned and performed a subtotal abdominal hysterectomy with bilateral salpingo-oophorectomy under general anesthesia. Anticoagulation was managed with a heparin infusion targeting an activated clotting time of 160–180 seconds to balance bleeding and thrombosis risk. Intraoperative management included invasive arterial pressure monitoring, echocardiography, continuous assessment of ECMO circuit flows, and inotropic support. ECMO flows were maintained between 2.2 and 2.6 L/min. Meticulous surgical and hemostatic techniques minimized blood loss. The patient tolerated the procedure without intraoperative complications and was successfully decannulated from ECMO on postoperative day six. However, she later developed limb ischemia, renal failure requiring continuous renal replacement therapy, and refractory multiorgan dysfunction, resulting in death on day nine. Discussion: Experience with noncardiac surgery during VA-ECMO is limited, with outcomes largely influenced by preexisting organ dysfunction rather than intraoperative factors. This case supports existing literature suggesting ECMO can enable time-critical surgery in carefully selected patients when managed by a coordinated multidisciplinary team. Conclusion: Urgent noncardiac surgery can be performed during VA-ECMO with careful planning, dynamic hemodynamic management, and multidisciplinary collaboration.