Percutaneous Pulmonary Artery Venting via Jugular Vein While on Peripheral Extracorporeal Life Support

Abstract

Peripheral extracorporeal membrane oxygenation (ECMO) setting remains a valid option to treat cardiogenic shock (CS). We investigated a percutaneous approach to unload the left ventricle (LV) while on veno-arterial (v-a) peripheral ECMO support. Between 2017 and 2018, eight patients (three females, mean age: 49.6 years old, and five males, mean age: 58 years old, respectively) suffered refractory CS due to acute myocardial infarction (n = 4), acute myocarditis (n = 2), acute decompensation on chronic heart failure (n = 1), and primary graft failure after heart transplantation (Htx) (n = 1), respectively. After a multidisciplinary CS team discussion, it was decided to proceed with peripheral v-a ECMO placement and percutaneous LV venting via right internal jugular vein access to drain the pulmonary artery (PA), in the hybrid operating room. In a single postcardiotomy case, the PA trunk was vented centrally. Mean ECMO support time was 8.5 days. Seven (87.5%) patients were successfully weaned from ECMO and one (12.5%) successfully bridged to Htx. All patients were successfully discharged after treatment except for a single case who died due to sepsis. In case of not recommended usage of LV apical venting, the adoption of v-a peripheral ECMO support associated with percutaneous PA drainage enables the rapid onset of extracorporeal life support with an effective biventricular unloading.

Dynamic extracorporeal life support: A novel management modality in temporary cardio‐circulatory assistance

“…Drainage from the PA cannula may, therefore, be influenced and limited by the drainage flow from the right atrium, with potential reduced drainage, stasis and ultimately thrombosis of the cannula placed in PA. To overcome or enhance an optimal flow (1.8-2 L/min) from the PA cannula and to avoid the risk of cannula clotting, the cannula flow from the right atrium needs to be regulated allowing minimal drainage from the PA itself avowing the abovementioned shortcomings. 7,8,29 This is performed using a Hoffman clamp (or gate clamp) ( Figure 3) to balance the proportion of blood from the systemic venous circulation and guarantee adequate drainage quote from the PA cannula. 9 In case of concomitant perfusion of an arterial vessel and the PA, like for differential hypoxemia, with a V-VA mode with the PA cannula as adjunct return, if no control of the PA cannula flow is exerted, the majority of the ECLS flow will go to the lower resistance cannula (the PA cannula), resulting in a remarkable, and potentially dangerous, reduction of perfusion via the systemic arterial cannula.…”

“…The PA cannula, if used as an adjunctive drainage point, is usually connected to the larger main draining cannula (often in right atrium cannula from the femoral vein). Drainage from the PA cannula may, therefore, be influenced and limited by the drainage flow from the right atrium, with potential reduced drainage, stasis and ultimately thrombosis of the cannula placed in PA. To overcome or enhance an optimal flow (1.8‐2 L/min) from the PA cannula and to avoid the risk of cannula clotting, the cannula flow from the right atrium needs to be regulated allowing minimal drainage from the PA itself avowing the abovementioned shortcomings 7,8,29 . This is performed using a Hoffman clamp (or gate clamp) (Figure 3) to balance the proportion of blood from the systemic venous circulation and guarantee adequate drainage quote from the PA cannula 9 .…”

“…The PA cannulation may be achieved with a single lumen cannula lighthouse tip cannula or with a double‐lumen cannula (DLC) (ProtekDuo, LivaNova/Tandem Life, Cardiac Assist Inc, Pittsburgh, PA, USA). As recently described, such a cannulation may be executed via minimally invasive percutaneous techniques, thereby minimizing the complications related to more aggressive approaches 7‐9 . Reduced cost, as compared to transaortic suction device, may also influence the decision‐making.…”

“…As recently described, such a cannulation may be executed via minimally invasive percutaneous techniques, thereby minimizing the complications related to more aggressive approaches. [7][8][9] Reduced cost, as compared to transaortic suction device, may also influence the decision-making.…”

Left ventricle unloading strategies in ECMO: A single‐center experience

“…In cases in which medical therapy is insufficient or not tolerated, mechanical means of unloading the LV are considered. Multiple approaches to LV unloading have been described and include: (a) atrial septostomy; (b) a surgically inserted transapical catheter; (c) intra‐aortic balloon pump (IABP); (d) percutaneous pulmonary artery venting via the jugular vein; and, (e) transvalvular percutaneous ventricular assist device (pVAD) such as the Impella CP (Abiomed, Danvers, MA) 14‐17 . Atrial septostomy and pulmonary artery venting act via reducing LV preload while pVADs and surgically placed transapical catheters directly unload the LV 18 .…”