Pulmonary artery cannulation to enhance extracorporeal membrane oxygenation management in acute cardiac failure

Abstract

OBJECTIVES Pulmonary artery (PA) cannulation during peripheral venoarterial extracorporeal membrane oxygenation (ECMO) has been shown to be effective either for indirect left ventricular (LV) unloading or to allow right ventricular (RV) bypass with associated gas-exchange support in case of acute RV with respiratory failure. This case series reports the results of such peculiar ECMO configurations with PA cannulation in different clinical conditions. METHODS All consecutive patients receiving PA cannulation (direct or percutaneous) from January 2015 to September 2018 in 3 institutions were retrospectively reviewed. Isolated LV unloading or RV support, as well as dynamic support including initial drainage followed by perfusion through the PA cannula, was used as part of the ECMO configuration according to the type of patient and the patient’s haemodynamic/functional needs. RESULTS Fifteen patients (8 men, age range 45–73 years, EuroSCORE log range 14.45–91.60%) affected by acute LV, RV or biventricular failure of various aetiologies, were supported by this ECMO mode. Percutaneous PA cannulation was performed in 10 patients and direct PA cannulation, in 5 cases. Dynamic ECMO management (initially draining and then perfusing through the PA cannula) was carried out in 6 patients. Mean ECMO duration was 9.1 days (range 6–17 days). One patient exhibited pericardial fluid during the implant of a PA cannula (no lesion found when the chest was opened), and weaning from temporary circulatory support was achieved in 14 patients (1 who received a transplant). Three patients (20%) died in-hospital, and 12 patients were successfully discharged without major complications. CONCLUSIONS Effective indirect LV unloading in peripheral venoarterial ECMO as well as isolated RV support can be achieved by PA cannulation. Such an ECMO configuration may allow the counteraction of common venoarterial ECMO shortcomings or allow dynamic/adjustable management of ECMO according to specific ventricular dysfunction and haemodynamic needs. Percutaneous PA cannulation was shown to be safe and feasible without major complications. Additional investigation is needed to confirm the safety and efficacy of such an ECMO configuration and management in a larger patient population.

Transaortic or Pulmonary Artery Drainage for Left Ventricular Unloading in Venoarterial Extracorporeal Life Support: A Porcine Cardiogenic Shock Model

“…To summarize, our findings showed and confirmed how Impella had major effects on PCWP and LVEDV. This was found also in a simulation study performed by Donker and collaborators in a closed-loop real-time computer model of CS 13 .…”

Left Ventricle Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock. Systematic Review and Meta-Analysis

“…A well recognized limitation of the retrograde aortic flow while on VA-ECMO is the increase of left ventricular (LV) afterload [10], which can potentially lead to high LV stress and may exacerbate myocardial ischemia thus delaying recovery from cardiogenic shock [11]. Elevated LV pressure can also promote LV dilatation and trigger ventricular arrhythmias, or, secondarily, increase left atrial pressure causing pulmonary edema [12].…”

Nitric Oxide Ventilation Improves Recirculation and Right Ventricular Function During Veno-Venous Extracorporeal Membrane Oxygenation in a COVID-19 Patient

“…Alternatively, a veno-arterial/venous configuration could support the RV in specific cases of refractory RV failure and avoid differential oxygenation. 15,16 It was opted to improve the recirculation fraction by pharmacologically reducing PH and subsequent TR. In current guidelines, iloprost is prescribed 6-to-9 times per day, as it has a relatively short half-life (15-30 minutes) and short working period, 17 potentially explaining the limited effect compared with continuously administered iNO in the authors' patient.…”

“…Alternatively, a veno-arterial/venous configuration could support the RV in specific cases of refractory RV failure and avoid differential oxygenation. 15 , 16 …”