CASE 4—2009 Severe Reexpansion Pulmonary Edema After Minimally Invasive Aortic Valve Replacement: Management Using Extracorporeal Membrane Oxygenation

aortic valve replacement. The patient described a 4-month history of progressive dyspnea on exertion that markedly reduced his exercise tolerance. He reported worsening orthopnea; a persistent, productive cough; paroxysmal nocturnal dyspnea; and swelling in his lower extremities, but he denied chest pain, palpitations, and syncope. The past medical history was notable for essential hypertension (treated with atenolol, losartan, and hydrochlorothiazide), hyperlipidemia (for which the patient received simvastatin), and type II diabetes mellitus (treated with insulin, glipizide, and metformin). The physical examination revealed a grade III of VI crescendo-decrescendo systolic murmur best heard in the left 2nd intercostal space that radiated to the carotid arteries bilaterally. Two-dimensional transthoracic echocardiography showed the presence of a heavily calcified trileaflet aortic valve with restricted leaflet motion consistent with severe aortic stenosis. Concentric left ventricular hypertrophy was present, but no regional wall motion abnormalities were observed. The mean and peak gradients across the aortic valve were determined to be 37.5 and 58.4 mmHg, respectively, by using continuous-wave Doppler echocardiography. Color Doppler blood flow mapping also indicated the presence of mild aortic insufficiency. The aortic valve area and left ventricular ejection fraction were estimated to be 0.93 cm 2 and 53%, respectively. A cardiac catheterization confirmed the echocardiography findings and also showed the absence of hemodynamically significant coronary artery stenoses. A posterior-anterior chest radiograph showed mild cardiomegaly and