Successful Decannulation of Hybrid ECMO Circuitry: The First Philippine Experience

We report the first VA-VAV-VV ECMO conversion in a 57-year-old Filipino female with persistent coronary insufficiency from toxic shock syndrome due to Streptococcus pyogenes bacteremia, acute respiratory distress syndrome, and Harlequin syndrome with progressive acute limb ischemia from cone snail venom poisoning. The patient came in via air ambulance transport because deteriorating clinical status after having stepped on a cone snail 3 days prior and developing severe dehydration from vomiting and passage of voluminous watery stools after eating a local delicacy. The patient was admitted at the ICU where after 3 days of treatment, the patient developed cardiac tamponade and underwent stat pleuropericardial windowing with pericardiocentesis. Due to increasing pressor requirements from the combined shock, Swan-Ganz catheterization was inserted and a VA-ECMO system was set up. There was gradual improvement in cardiac hemodynamics, however oxygen requirement was increasing and both lower extremities became progressively violaceous with decreasing pulses. Harlequin syndrome was ruled in, the multidisciplinary team decided to convert to VAV hybrid circuit by adding a venous access by way of the right internal jugular vein. Improvement in oxygenation lead to eventual conversion from VAV to purely VV dedicated circuit. Ultrafiltration via ECMO was likewise done because of worsening azotemia and oliguria. The patient was then gradually weaned off from ECMO and was successfully decannulated after 8 days. Below knee amputation was done to address the progressive acute limb ischemia. The patient was nutritionally built up and physically rehabilitated and was eventually discharged improved on the 28th hospital day.

Iatrogenic Harlequin syndrome after thoracic spine surgery: a case report and literary review

Here we present a unique case of Harlequin syndrome without Horner syndrome after contralateral Th3 intradural tumor resection. Harlequin sign in our case presented probably to resection of sympathetic nerves while removing meningioma. Syndrome is rare in neurosurgical procedure, but we think that surgeons must be aware of it.

Managing Harlequin Syndrome in VA-ECMO – do not forget the right ventricle

Harlequin Syndrome (also known as North-South Syndrome) is a complication of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) that can occur when left ventricular function starts to recover. While most commonly due to continued impaired gas exchange in the lungs, we present a case caused by right ventricular dysfunction, successfully managed by conversion of the ECMO circuit to a veno-veno-arterial (VV-A) configuration.