Percutaneous venopulmonary artery extracorporeal membrane oxygenation for right heart failure after left ventricular assist device insertion

Abstract

OBJECTIVES Right ventricular failure after left ventricular assist device (LVAD) insertion is associated with significant mortality and morbidity. Mechanical support options include right ventricular assist devices, venoarterial extracorporeal membrane oxygenation (ECMO) and venopulmonary artery ECMO, the latter often involving central cannulation. We sought to evaluate the feasibility and early outcomes of a truly percutaneous venopulmonary artery (pVPA) ECMO strategy, with the potential advantage of bedside removal once weaned. METHODS Data from a single tertiary centre were reviewed retrospectively from January 2014 to January 2019. During this time, 54 patients underwent LVAD insertion, with 19 requiring mechanical support for right ventricular failure. Among them, 10 patients received pVPA ECMO. Implantation of the pVPA ECMO was performed under transoesophageal echocardiography and fluoroscopy guidance, with an inflow cannula placed in the right atrium via the right femoral vein and an outflow cannula placed in the left pulmonary artery (PA) via the right internal jugular vein. RESULTS Cannula insertion was 100% successful with no need for repositioning. Eight patients (80%) were able to be successfully weaned (at the bedside); 6 were discharged from the hospital and there were no cases of early sepsis, mediastinitis or thromboembolism. At follow-up, 5 patients had received transplants (50%), with 1 on LVAD support as destination therapy (10%). Survival was 60 ± 15% and 50 ± 16% at 6 and 12 months, respectively. CONCLUSIONS pVPA ECMO is 100% technically feasible and is an efficient method for temporary right ventricular support after LVAD insertion with the advantage of simple bedside removal and avoidance of a PA graft remnant in the chest cavity.

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

“…Twenty-one patients were treated for secondary RHF while on V-V ECMO with conversion to PA return ECMO. The patients were predominantly male (81%), obese (BMI 34 kg/m 2 [29][30][31][32][33][34][35][36][37][38][39]), and being treated for respiratory failure secondary to SARS-CoV-2 pneumonia (COVID-19) (90%). Patient characteristics are described further in Table 1.…”

“…34 Napp et al (2017), Uribarri et al (2019), Lorusso et al (2020), and Joshi et al (2021) reported percutaneous cannulation of the PA for primary cardiogenic shock with prophylactic use of an oxygenator in 1, 1, 2, and 10 patients, respectively, for an average of 6, 3, 9.1, and 9.5 days of support. 35–38 Direct PA cannulation for drainage using a standard venous ECMO cannula also has been reported as a method of LV unloading while on V-A ECMO, 36,39–41 as has percutaneous PA cannulation for use as an RVAD without an oxygenator. 42,43…”

“…34 2021) reported percutaneous cannulation of the PA for primary cardiogenic shock with prophylactic use of an oxygenator in 1, 1, 2, and 10 patients, respectively, for an average of 6, 3, 9.1, and 9.5 days of support. [35][36][37][38] Direct PA cannulation for drainage using a standard venous ECMO cannula also has been reported as a method of LV unloading while on V-A ECMO, 36,[39][40][41] as has percutaneous PA cannulation for use as an RVAD without an oxygenator. 42,43 Concerns regarding PA cannulation include the risk of pulmonary hemorrhage in the setting of high PA flows and valvular damage.…”

Experience with percutaneous right ventricular support in the early post-left ventricular assist device implantation period (clinical case report and literature reviews)

“…В случае сопутствующих критических нарушений газообменной функции легких (гипоксемия/гиперкапния) ПЖО может быть дополнен экстракорпоральной мембранной оксигенацией (ЭКМО). Отдельные исследования демонстрируют лучшие показатели выживаемости при сочетании ПЖО с ЭКМО [34,35]. Необходимо поддерживать более низкую производительность ПЖО по отношению к ЛЖО, уровень которой не должен превышать 4,0 л/мин у взрослых пациентов, чтобы обеспечить профилактику развития отека легких или легочного кровотечения [36].…”

Prediction, prevention, and management of right ventricular failure after left ventricular assist device implantation: A comprehensive review

“…The cannula is connected to an extracorporeal centrifugal pump [either Lifesparc R (LivaNova, London, UK), ECMO or CentriMag R console], able to provide flow up to 4-4.5 L/min (284), and allows for the connection of an oxygenator. The ProtekDuo R has been successfully used in LVAD patients and is approved for up to 30 days of use (285)(286)(287). Its jugular insertion allows for patient ambulation and better rehabilitation, but can also cause superior vena cava syndrome given the large cannula size (288).…”