Recurrent postoperative pulmonary hemorrhage complicated by asphyxia-induced cardiac arrest successfully managed with extracorporeal membrane oxygenation in an infant: a case report

This report describes an infant who experienced two distinct episodes of postoperative pulmonary hemorrhage after a Rastelli-type procedure, each driven by a different mechanism requiring tailored management. The initial right-sided pulmonary hemorrhage was attributed to excessive flow through major aortopulmonary collateral arteries (MAPCAs). Although hemostasis could not be achieved by coil embolization alone, selective temporary occlusion using balloon catheter limited the bleeding to a more segmental distribution. Despite airway obstruction leading to cardiac arrest, bleeding did not worsen under veno-arterial extracorporeal membrane oxygenation (VA-ECMO), which allowed stabilization and ultimately resulted in full recovery. The subsequent left-sided pulmonary hemorrhage was likely caused by elevated left atrial pressure following moderate residual atrioventricular valve regurgitation. Decompression with temporary left atrial venting, followed by atrial septal defect (ASD) creation, resulted in marked improvement. This case illustrates that VA-ECMO can be lifesaving even in pediatric cardiac arrest caused by massive pulmonary hemorrhage when ventilation becomes impossible. It also highlights that left atrial decompression-including ASD creation-can be an effective therapeutic strategy for pulmonary hemorrhage driven by elevated left atrial pressure. Furthermore, it suggests that selective balloon occlusion may help localize and attenuate bleeding in MAPCA-related pulmonary hemorrhage.