Triple Cannulation ECMO

Abstract

Extracorporeal membrane oxygenation (ECMO) has emerged as an invaluable tool for bridging severe isolated or combined failure of lung and heart. Due to massive technical improvements, the application of ECMO is growing fast. While historically ECMO was initiated and maintained by cardiac surgeons, in recent times interventional cardiologists and intensive care specialists increasingly run ECMO systems independently with great success. Percutaneous ECMO circuits are usually set up in a dual cannulation mode, either as veno-venous or as veno-arterial configuration. A novel advanced strategy is the cannulation of three large vessels (triple cannulation), resulting in venoveno-arterial or veno-arterio-venous cannulation. Both veno-venous and veno-arteriovenous cannulation may further be upgraded to veno-pulmonary-arterial or venoarterial-pulmonary arterial cannulation, respectively. Triple cannulation expands the field of ECMO application but substantially increases the complexity of ECMO circuits. In this chapter, we review percutaneous dual and triple cannulation strategies, featuring a recently proposed unifying nomenclature. This unequivocal code universally applies to both dual and triple cannulation strategies (VV, VPa, VA, VVA, VAV, VAPa). The technical evolution of ECMO is growing fast, but it has to be noted that current knowledge of ECMO support is mainly based on observation. Thus controlled trials are urgently needed to prospectively evaluate different ECMO modes.

ECMO in cardiac arrest and cardiogenic shock

“…In addition to the VA circuit, the additional venous cannula adds preoxygenated blood to the lungs and thereby establishes a “VV component.” This ensures sufficient oxygen content of blood ejected by the heart and allows for lung protective ventilation. Of note, VAV-ECMO requires sufficient RV function, otherwise it may be necessary to relocate the venous-supplying cannula into the pulmonary artery [49] for bypassing the RV. Retrospective studies suggest efficacy of VAV cannulation for rescue of body oxygenation and recovery of lung failure [50–52], but prospective studies are needed to confirm the observed benefit.

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“…In these patients an elegant and very effective treatment is upgrading the ECMO circuit to a triple-cannulated ECMO, with one venous-draining, one arterial-supplying, and one venous-supplying cannula (“VAV-ECMO”, Fig. 3 ; [ 36 , 49 ]). In addition to the VA circuit, the additional venous cannula adds preoxygenated blood to the lungs and thereby establishes a “VV component.” This ensures sufficient oxygen content of blood ejected by the heart and allows for lung protective ventilation.…”

“…Flow through the returning cannulae is balanced with an adjustable clamp and monitored with a separate flow sensor on the upper return cannula. (Modified from Napp & Bauersachs [ 49 ]; © L. C. Napp, J. Bauersachs 2016. This publication is an open access publication, available on intechopen.com)…”

“…This “unloads” the LV and facilitates myocardial recovery and pulmonary decongestion. (Modified from Napp & Bauersachs [ 49 ]; © L. C. Napp, J. Bauersachs 2016. This publication is an open access publication, available on intechopen.com)…”

Emerging therapeutics in the management of COVID-19

“…Newly oxygenated blood then flows through the normal circulatory pathways to provide oxygen to the rest of the body. V-V ECMO settings require that the patient’s heart is functioning appropriately to ensure adequate blood distribution[ 152 ]. Suggested criteria for V-V ECMO use are PaO2/FiO2 < 100 mmHg, PCO2 > 60 mmHg, and/or arterial pH < 7.2[ 153 ].…”