Application of veno-arterial-venous extracorporeal membrane oxygenation in differential hypoxia

Abstract


 
 
 
 Veno-arterial extracorporeal membrane oxygenation (ECMO) through the femoral vein and artery may cause differential hypoxia, i.e., lower PaO2 in the upper body than in the lower body, because of normal cardiac output with severe impairment of pulmonary function. Hereby, we report the diagnosis and the treatment of differential hypoxia caused by veno-arterial ECMO. A 39-year-old man received cardiopulmonary resuscitation from a cardiac arrest due to acute myocardial infarction. Even after more than 30 min of resuscitation, spontaneous circulation had not resumed. Next, we performed veno-arterial ECMO through the femoral artery and vein, and the patient recovered consciousness on the second day of ECMO. On day 5 of ECMO, he lost consciousness again and presented a generalized tonic-clonic seizure, and an electroencephalogram showed delta waves suggesting diffuse cerebral cortical dysfunction. While an echocardiogram revealed improvements in myocardial function, a follow up chest radiograph showed increasing massive parenchymal infiltrations, and gas analysis of blood from the right radial artery revealed severe hypoxemia. These findings indicated a definite diagnosis of differential hypoxia, and therefore, we inserted a 17-Fr cannula into the left subclavian vein as a return cannula. The patient’s consciousness and pulmonary infiltrations were improved 2 days after veno-arterial-venous ECMO, and the electroencephalogram showed normal findings. To our knowledge, this is the first report of successful clinical management of differential hypoxia. We suggest that veno-arterial-venous ECMO could be the treatment of choice for differential hypoxia resulting from veno-arterial ECMO.
 
 
 

Double, triple and quadruple cannulation for veno-arterial extracorporeal membrane oxygenation support: is there a limit?

“…This type of support is called veno-arterio-venous (VAV) support. Here, part of the arterial outflow is directed toward the right atrium and to the pulmonary vasculature thus oxygenating the coronary arteries and the upper body more efficiently (Figure 3) (4). The amount of arterial outflow to the venous side can be altered with a Hoffman Clamp if systemic circulatory support is critically lowered.…”

A Review of percutaneous mechanical support devices and strategies

“…In contrast, areas proximal to the watershed receive blood from the left ventricle, and the oxygen saturation of this native blood can be low due to pulmonary edema, pneumonia or other pulmonary conditions. Thus, despite a seemingly suitable perfusion pressure and CPO, respiratory failure during VA ECMO can result in anoxic brain injury, myocardial ischemia and weaning failure from ECMO (Choi et al, 2014).…”

Hybrid Extracorporeal Membrane Oxygenation Using Avalon Elite Double Lumen Cannula Ensures Adequate Heart/Brain Oxygen Supply

“…To solve this problem, an additional venous infusion cannula on an existing femoral-femoral VA ECMO circuit was proposed to establish VAV ECMO. This venous infusion cannula placed in a major vein introduces oxygenated blood into the venous-pulmonary system, raising the oxygen level in the LV and ascending aorta [6,9,12]. However, the long downstream drainage cannula in the RA in the VA ECMO circuit partially drains oxygenated blood from the additional venous infusion cannula, leading to recirculation [10].…”

“…Therefore, the upper body oxygen supply is strictly dependent on native lung function. When lung function is compromised, the left ventricle (LV) pumps poorly saturated blood from the native lung to the ascending aorta for upper body perfusion, resulting in relative hypoxia to the heart, or heart plus brain [5][6][7]. Venoarteriovenous (VAV) ECMO has been used to address this differential hypoxia.…”

“…Venoarteriovenous (VAV) ECMO has been used to address this differential hypoxia. Venoarteriovenous ECMO adds VV blood flow into the pulmonary circulation onto the existing VA ECMO circuit, elevating oxygen saturation in the LV and ascending aorta and mitigating heart and brain hypoxia [6,[8][9][10]. Most of these VAV ECMO cases used three-site cannulations with separate single lumen cannulas.…”