Severe heart failure patients are sometimes complicated with alveolar hemorrhage due to pulmonary congestion. Patients with alveolar hemorrhage have high pulmonary vascular resistance, so LVAD attachment induces relative right heart failure which may require right heart system assist. In such cases, hemodynamic management becomes very difficult. With high pulmonary perfusion as well as intensive anti-coagulation therapy, alveolar hemorrhage might worsen. Furthermore, it is difficult to tell whether the cause of alveolar hemorrhage is pulmonary congestion or other diseases like organized pneumonia. Our present strategy for particularly severe heart failure is as follows: we adopt central ECMO support with RA drainage and ascending aorta perfusion to get adequate circulatory flow support. At the same time, LV venting from the apex is also used to release pulmonary congestion, which leads to recover pulmonary function, and reduce pulmonary vascular resistance. And as a next step, we aim to maintain hemodynamics by supporting left heart system only. Recently, we experienced 2 severe heart failure cases complicated with alveolar hemorrhage whose etiologies were hard to differentiate, which were successfully treated according to our strategy. Here, we are going to report these 2 cases with some discussions.
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