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Percutaneous Single-Site Cannulation for Acute Right-Sided Support

Malik, Mahim*; Kilic, Ahmet; Whitson, Bryan A.

doi: 10.1097/MAT.0000000000000556
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Right ventricular failure is a challenging problem after left ventricular assist device implantation, leading to considerable morbidity and mortality. When inotropic support is no longer adequate, a temporary right ventricular assist device is needed that often mandates reopening of the sternotomy for implant and explant. We describe our technique to percutaneously place a right internal jugular cannula for extracorporeal support.

From the *Department of Surgery, University of Washington, Seattle, Washington; and Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.

Submitted for consideration November 2016; accepted for publication in revised form February 2015.

Disclosure: The authors have no conflicts of interest to report.

Correspondence: Bryan A. Whitson, Division of Cardiac Surgery, The Ohio State University Wexner Medical Center, N-816 Doan Hall, 410 W. 10th Ave., Columbus, OH 43210. Email: bryan.whitson@osumc.edu.

End-stage heart failure is increasingly being managed by left ventricular assist devices.1 However, the postoperative course can be complicated by acute right ventricular (RV) failure in 10–40% patients, requiring either extended inotropic support or temporary mechanical support.2–5 Right ventricular assist devices are placed either at the time of the initial operation or in the immediate postoperative period. In the postoperative, open technique, central cannulation of the right atrium and main pulmonary artery necessitates resternotomy for placement and then again for removal of the cannulas after recovery.3

The utilization of a percutaneous, single-site, right internal jugular vein (RIJ) cannula for extracorporeal support mitigates the morbidity of repeat sternotomies and allows for the potential of ambulation not afforded with other percutaneous approaches. We describe our technique for percutaneous RIJ placement of a commercially available cannula (Protek-Duo cannula [CardiacAssist, Pittsburgh, PA] is a dual lumen 29 Fr cannula, with an insertion length of 46 cm) under fluoroscopic guidance.

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Technique

  1. The patient is brought to the operating room and placed in supine position. Intravenous systemic anticoagulation is administered to ensure an activated clotting time in excess of 250.6,7
  2. Sterile percutaneous access to the RIJ vein (Figure 1A) is obtained. The vein is optimally accessed under ultrasound guidance using stander Seldinger technique, with placement of 6 Fr introducer sheath.
  3. A sterile Swan-Ganz catheter is then advanced to the pulmonary artery (PA) under fluoroscopy (Figure 1B).
  4. A 0.025 wire is then introduced through the pulmonary artery catheter and advanced into the right pulmonary artery, with subsequent removal of the catheter and introducer sheath.
  5. The 0.025 wire is exchanged for the stiff Lunderquist 0.035 wire (Cook Medical, Bloomington, IN) over a 6 Fr exchange catheter (Figure 1C).
  6. The tract is dilated to 29 Fr caliber using sequential dilators. This is performed under fluoroscopic visualization, to ensure that there is no migration of the Lunderquist wire. We prefer to use endovascular dilators, for their flexibility and length. Dilation is performed to the level of the right atrium.
  7. The Protek-Duo cannula is then introduced over the wire, into the right pulmonary artery (Figure 2A). Cannula position is observed upon removal of the introducer sheath (Figure 2B) with final position, and positioning of proximal lumen in the right atrium is confirmed (Figure 2C).
  8. After appropriate deairing, proximal (inflow-right atrial [RA]) and distal (outflow-PA) lumens are then connected to a centrifugal blood pump (e.g., Centrimag, St. Jude Medical), and extracorporeal support initiated.
  9. Cannula position can be followed in the intensive care unit with chest x-ray (Figure 2D).
  10. The cannula is secured to the skin and behind the ear (Figure 3A). This positioning allows for comfort and ambulation (Figure 3B). After recovery, the cannula can be removed with ease. Because of the large caliber of the cannula, we prefer to perform this in the operating room under conscious sedation.
Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

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Comment

The right ventricle has shown remarkable ability to regain function relatively quickly, supporting the use of a temporary assist device as a bridge to transplant or recovery.8,9 Over the past 2 decades, multiple devices have been used to offload the right ventricle and provide temporary support while it recovers. With an increasing number of left ventricular assist devices performed each year, there is an increasing need for a device that can be inserted/removed percutaneously without the need for reopening the sternotomy.

The Impella RP (Abiomed, Danvers, MA) is one such Food and Drug Administration-approved and is a 21 Fr axial flow pump that is inserted via femoral access. Early results from the Recover Right trial with the Impella RP showed safety and ease of insertion, with evidence of hemodynamic recovery.10 However, the use of the Impella device can be complicated, and with its insertion via the femoral vein, patient mobility is restricted.

The Protek-Duo cannula was initially Food and Drug Administration-approved for venovenous extracorporeal life support for pulmonary failure. The cannula can be inserted percutaneously and is typically coupled with a centrifugal blood pump. The use of this RIJ access to the RA/RV and pulmonary artery allows for the ability to provide pure RV support or pulmonary and RV support for severe, refractory respiratory failure, when an oxygenator is included in the perfusion circuit. The percutaneous RIJ approach would be superior in that equivalent flows to other cannulation strategies are achieved but without the morbidity of two sternotomies in the central cannulation approach or the immobility of multisite peripheral cannulation (e.g., RIJ drainage to right femoral vein return).

In conclusion, we describe the technique of percutaneous placement of a RIJ, single-site cannula for temporary RV or venovenous extracorporeal life support. This approach carries the potential for decreasing the morbidity associated with the traditional, open approach.

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References

1. Rose EA, Gelijns AC, Moskowitz AJ, et al; Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group: Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med 2001.345: 1435–1443.
2. Kormos RL, Teuteberg JJ, Pagani FD, et al; HeartMate II Clinical Investigators: Right ventricular failure in patients with the HeartMate II continuous-flow left ventricular assist device: Incidence, risk factors, and effect on outcomes. J Thorac Cardiovasc Surg 2010.139: 1316–1324.
3. Loforte A, Montalto A, Lilla Della Monica P, Musumeci F. Simultaneous temporary CentriMag right ventricular assist device placement in HeartMate II left ventricular assist system recipients at high risk of right ventricular failure. Interact Cardiovasc Thorac Surg 2010.10: 847–850.
4. Lo C, Murphy D, Summerhayes R, et al. Right ventricular failure after implantation of continuous flow left ventricular assist device: Analysis of predictors and outcomes. Clin Transplant 2015.29: 763–770.
5. Fida N, Loebe M, Estep JD, Guha A. Predictors and management of right heart failure after left ventricular assist device implantation. Methodist Debakey Cardiovasc J 2015.11: 18–23.
6. Whitson BA. Surgical implant techniques of left ventricular assist devices: An overview of acute and durable devices. J Thorac Dis 2015.7: 2097–2101.
7. Whitson BA, Hryniewicz K, John R. Raman J. Acute mechanical circulatory support: Bridge to recovery or decision. in Management of Heart Failure, Vol 2016.2: 2nd ed, Springer, Surgical.
8. Lang SA, O’Neill B, Waterworth P, Bilal H. Can the temporary use of right ventricular assist devices bridge patients with acute right ventricular failure after cardiac surgery to recovery? Interact Cardiovasc Thorac Surg 2014.18: 499–510.
9. Bowers TR, O’Neill WW, Grines C, Pica MC, Safian RD, Goldstein JA. Effect of reperfusion on biventricular function and survival after right ventricular infarction. N Engl J Med 1998.338: 933–940.
10. Aggarwal V, Einhorn BN, Cohen HA. Current status of percutaneous right ventricular assist devices: First-in-man use of a novel dual lumen cannula. Catheter Cardiovasc Interv 2016.88: 390–396.
Keywords:

ECMO; percutaneous; RVAD; ECLS

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