Percutaneous Pulmonary Artery Cannulation to Treat Acute Secondary Right Heart Failure While on Veno-venous Extracorporeal Membrane Oxygenation

Abstract

Right heart failure (RHF) is a common, yet difficult to manage, complication of severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation (ECMO) that is associated with increased mortality. Reports of the use of percutaneous mechanical circulatory support devices for concurrent right heart and respiratory failure are limited. This series describes the percutaneous cannulation of the pulmonary artery for conversion from veno-venous to veno-pulmonary artery return ECMO in 21 patients who developed secondary RHF. All patients cannulated between May 2019 and September 2021 were included. Either a 19 or 21 French venous cannula was placed percutaneously into the pulmonary artery via the internal jugular or subclavian vein, providing a total of 821 days of support (median 23 [4-71] days per patient) with flows up to 6 L/min. Five patients underwent cannulation at the bedside, with the remainder performed in the cardiac catheterization laboratory. Pulmonary artery cannulation occurred after 12 [8.5-23.5] days of ECMO support. Vasoactive infusion requirements decreased significantly within 24 hours of pulmonary artery cannula placement (p = 0.0004). Nonetheless, 75% of these patients expired after a median of 12 [4-63] days of support, with three patients found to have had significant pericardial effusions peri-arrest. This cannulation technique may be an effective alternative to veno-arterial ECMO cannulation or the placement of a dual-lumen cannula for the treatment of RHF.

Veno-Pulmonary Arterial Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome: Should We Consider Mechanical Support of the Pulmonary Circulation From the Outset?

“…The median time from V-V ECMO initiation to conversion to V-PA ECMO was 12 (8.5–23.5) days, and survival to hospital discharge was only 25%. 31 These data indicate that application of V-PA ECMO in advanced RV injury and despite V-V ECMO support may not significantly alter outcomes. Perhaps pre-emptive V-PA ECMO or application of V-PA ECMO in ARDS patients with RV injury phenotypes where the RV meets flow demand, that is, before RV failure and secondary organ injuries develop, would make more physiologic sense; this notion, however, should be supported by prospective randomized data.…”

“…Current V-PA ECMO literature is limited to observational data (Table 1). [23][24][25][26][27][28][29][30][31][32] A recent systematic review of five observational studies including 194 patients with coronavirus disease 2019 (COVID-19)related ARDS receiving V-PA ECMO showed that application of V-PA ECMO, using single-site dual-lumen RA-to-PA cannula was associated with high survival rates. 32 Veno-pulmonary arterial ECMO was also associated with reduced incidence of acute kidney injury (AKI) and need for renal replacement therapy (RRT).…”

“…In the majority of V-PA ECMO studies, there is a lack of cardiovascular phenotypic characterization of the study population before application of ECMO. [23][24][25][26][27][28][29][30][31] Patients who met ECMO criteria and required extracorporeal support received V-PA ECMO as a prophylactic measure and not based on their echocardiographic or pulmonary hemodynamic profile. Given the observational nature of available data and despite a signal of outcome benefit, there is a need to enhance the precision in individual delivery of V-PA ECMO in ARDS.…”

“…20,24,25,36 It is unknown whether personalization of V-PA ECMO to certain phenotypes of abnormal RV biomechanics in ARDS (e.g., isolated RV dilatation, RV dilatation with impaired function when the RV still meets flow demand or advanced RV injury/failure with circulatory shock) would improve outcomes. 6 In a recent study published in the journal, Ivins-O'Keefe et al 31 described a case series of 21 patients with ARDS who developed acute RV failure despite standard V-V ECMO, requiring conversion to a V-PA ECMO configuration (dual-site cannulation with PA return). The median time from V-V ECMO initiation to conversion to V-PA ECMO was 12 (8.5-23.5) days, and survival to hospital discharge was only 25%.…”

The Use of Cardioprotective Devices and Strategies in Patients Undergoing Percutaneous Procedures and Cardiac Surgery

“…One of them is that it drains only from the superior vena cava, making it harder to place it correctly in shorter patients. Additionally, it is more expensive than a standard ECMO cannula; the cost is estimated to be more than USD 20,000 [ 47 ].…”