Comparison of venoarterial versus venovenous access in the cerebral circulation of newborns undergoing extracorporeal membrane oxygenation

Abstract

This study was designed to compare venoarterial (VA) with venovenous (VV) access in the cerebral circulation of newborn infants during extracorporeal membrane oxygenation (ECMO). Among 14 infants with VA ECMO, 7 had no intracranial complications (group 1), while the others (group 2) developed intracranial hemorrhage (ICH). In contrast, among 19 infants with VV ECMO, only 1 developed ICH. Serial echocardiograms were performed before and after 1, 6, 12, and 24 h and 2 and 3 days of ECMO. The mean cerebral blood flow (CBF) velocities were measured in the anterior cerebral artery (ACA), right and left internal carotid arteries (Rt, Lt-ICA), basilar artery (BA), and right and left middle cerebral arteries (Rt, Lt-MCA). Ejection fraction (EF), cardiac output (CO), and stroke volume (SV) were also measured using standard echography. The velocity levels in the ACA, Rt-MCA, and Lt-MCA in VA ECMO were lower than those in VV ECMO, while those in the Lt-ICA and BA in VA ECMO were higher than those in VV ECMO. The EF, CO, and SV were lower in cases of VA ECMO than in VV ECMO. In cases of VA ECMO, there were no differences between groups 1 and 2 in velocities in the ACA, Rt-ICA, or Lt-ICA. However the velocities in group 2 in the BA, Rt-MCA, and Lt-MCA were lower than those in group 1 before and during ECMO. Similarly, the EF, CO, and SV were lower in group 2 (12.0%-31.0%, 0. 10-0.32 l/min, and 0.66-1.55 ml, respectively) than in group 1 (29. 5%-49.3%, 0.25-0.63 l/min, and 2.15-3.85 ml) during ECMO. However, in the infants on VV ECMO the CBF was either maintained or gradually increased before and during ECMO. Their cardiac parameters were: EF 46.1%-53.0%, CO 0.43-0.52 l/min, and SV 2.72-3.84 ml during ECMO. It is concluded that in VA ECMO CBF velocities, particularly in infants who developed ICH, decreased after the onset of ECMO in association with poor cardiac function, while in VV ECMO they were stable, probably due to normal systemic hemodynamics and cardiac function.

Extracorporeal membrane oxygenation for respiratory failure: Comparison of venovenous versus venoarterial bypass

“…Fukuda et al demonstrated that VV ECMO had advantages in stabilizing brain hemodynamics compared with VA ECMO. 13 Roberts et al also recommended VV ECMO for neonatal respiratory failure in all cases, except where double lumen cannulation is impossible, or when septic shock is refractory to inotropic support. 14 Extracorporeal membrane oxygenation has been also used for the treatment of adults with severe respiratory failure since the 1970s, and two randomized trials showed no superiority of ECMO over conventional treatment.…”

Extracorporeal Membrane Oxygenation and Cerebral Blood Flow Velocity in Children

“…This reduction persisted when re-evaluated 8 hours later. Fukuda et al (23) evaluated cerebral blood flow velocities in 14 infants on venoarterial ECMO and 19 infants on venovenous ECMO. These patients had a reduction from baseline values in bilateral MCA flow velocities during the 12 hours following cannulation for both venoarterial and venovenous ECMO, although the reductions were much more dramatic in the venoarterial group of patients.…”

“…Following ligation and cannulation of the internal jugular vein, patients on both venovenous and venoarterial ECMO experience increased cerebral venous congestion which may contribute to decreased CBFV in these patients (25, 26). Lastly, patients requiring venoarterial ECMO often have significantly reduced cardiac function (both ejection fraction and cardiac output) with cerebral blood flow then becoming primarily pump dependent (23). Pump flow is characterized by decreased systolic upstroke, lack of dichrotic notch, and continuous diastolic flow (22).…”

ECMO Maintains Cerebral Blood Flow During Endotoxic Shock in Piglets

“…5–7 In both human and animal ECMO models, cerebrovascular injury appears to be more closely associated with reperfusion of ischemic cerebral tissue. 8 The porcine central nervous system, more specifically the brain, has been utilized as a proxy human model given similarities in size and anatomic characteristics. 9,10 More specifically, the pattern of piglet brain injury on coronary bypass approximates neonatal brain injury patterns and is localized to the neocortex and hippocampus.…”