Hemodynamic and recirculation performance of dual lumen cannulas for venovenous extracorporeal membrane oxygenation

Abstract

Venovenous extracorporeal membrane oxygenation (ECMO) can be performed with two single lumen cannulas (SLCs) or one dual-lumen cannula (DLC) where low recirculation fraction ($${R}_{f}$$ R f ) is a key performance criterion. DLCs are widely believed to have lower $${R}_{f}$$ R f , though these have not been directly compared. Similarly, correct positioning is considered critical although its impact is unclear. We aimed to compare two common bi-caval DLC designs and quantify $${\mathrm{R}}_{\mathrm{f}}$$ R f in several positions. Two different commercially available DLCs were sectioned, measured, reconstructed, scaled to 27Fr and simulated in our previously published patient-averaged computational model of the right atrium (RA) and venae cavae at 2–6 L/min. One DLC was then used to simulate ± 30° and ± 60° rotation and ± 4 cm insertion depth. Both designs had low $${R}_{f}$$ R f (< 7%) and similar SVC/IVC drainage fractions and pressure drops. Both cannula reinfusion ports created a high-velocity jet and high shear stresses in the cannula (> 413 Pa) and RA (> 52 Pa) even at low flow rates. Caval pressures were abnormally high (16.2–23.9 mmHg) at low flow rates. Rotation did not significantly impact $${R}_{f}$$ R f . Short insertion depth increased $${R}_{f}$$ R f (> 31%) for all flow rates whilst long insertion only increased $${R}_{f}$$ R f at 6 L/min (24%). Our results show that DLCs have lower $${R}_{f}$$ R f compared to SLCs at moderate-high flow rates (> 4 L/min), but high shear stresses. Obstruction from DLCs increases caval pressures at low flow rates, a potential reason for increased intracranial hemorrhages. Cannula rotation does not impact $${R}_{f}$$ R f though correct insertion depth is critical.

Therapeutic Hypothermia for Refractory Hypoxemia on Venovenous Extracorporeal Membrane Oxygenation: An In Silico Study

“…A well-placed double lumen catheter VV-ECMO configuration has less recirculation than two catheter configurations. 28 Patient scenarios A, B, and C examined the effect of hypothermia when cardiac output was high compared with ECMO blood flow, in a configuration with IVC drainage and RA return. As there was no recirculation in these scenarios, the findings of this study should apply to a double lumen catheter configuration.…”

ECMO utilization in lung transplantation

“…The color of the blood in the venous drainage cannula will also appear as bright red as the blood in the reinfusion cannula. This typically occurs when the cannulas are too close together for two-site cannulation or if the reinfusion port is not directed correctly in the single-site cannulation, although the risk of recirculation is much less with the dual lumen cannula [11]. The position of the cannulas can be confirmed with fluoroscopy, chest x-ray, or echocardiography and adjustment of the cannula position can resolve the recirculation [9].…”

“…The PA to LA negative pressure gradient allows a pumpless strategy that creates an oxygenated right-toleft shunt [10]. It carries the great advantages of maintaining the left heart preload to allow accurate LV assessments with echography (in contrast, LV assessment is rendered very challenging when the heart is offloaded with p or cVA ECMO), and LV remodeling to start occurring even before the transplant [11]. Technically, this is a two-step procedure entailing first a pVA ECMO cannulation for hemodynamic stability, then either sternotomy for direct PA and R superior pulmonary vein cannulation, or L anterior minithoracotomy for L main PA and L superior pulmonary vein cannulation.…”