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Case Report

Dual RVAD-ECMO Circuits to Treat Cardiogenic Shock and Hypoxemia Due to Necrotizing Lung Infection: A Case Report

Rosenbaum, Andrew N. MD*; Bohman, John K. MD; Rehfeldt, Kent H. MD; Stulak, John M. MD; Daly, Richard C. MD; Klompas, Allan M. MBBCh, BAO; Behfar, Atta MD, PhD*,§,‖; Yalamuri, Suraj M. MD

Author Information
A & A Practice: April 2020 - Volume 14 - Issue 6 - p e01181
doi: 10.1213/XAA.0000000000001181
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Abstract

Extracorporeal membrane oxygenation (ECMO) has seen a dramatic increase in utilization in recent years: a near 4-fold increase in venovenous-ECMO (VV-ECMO) for respiratory failure and greater than 4-fold increase for venoarterial-ECMO (VA-ECMO) for treatment of cardiogenic shock from 2010 to 2015.1 Occasionally, VA-ECMO is also required in the context of respiratory failure if there is superimposed cardiogenic shock. Recent data from the Extracorporeal Life Support Organization (ELSO) registry indicate that VA-ECMO is utilized in approximately 14%–20% of cases of acute respiratory distress syndrome (ARDS).2

Effective utilization of ECMO therapy requires calculation of the estimated delivery of oxygen (DO2) to effectively meet the physiologic demands of the patient.3 Cannula sizing to meet minimum optimal flow, hemoglobin concentration, and native cardiopulmonary function are all essential considerations to optimize oxygen delivery to tissues when considering modes of extracorporeal cardiopulmonary support. However, anatomic constraints may prevent the use of sufficiently sized cannula for optimal flow, becoming the limiting factor for achieving the desired level of support, thereby potentially limiting the efficacy of mechanical support.

We describe the utilization of dual central and percutaneous VA-ECMO circuits in a right ventricular assist device (RVAD) configuration (VRA − APA\(dl)V − P—surgical RVAD and percutaneous dual-lumen right atrium [RA] to pulmonary artery [PA] catheter4) to provide sufficient oxygen delivery in the setting of respiratory failure complicated by severe right ventricular (RV) failure. Health Insurance Portability and Accountability Act (HIPAA) authorization for the use of protected health information was obtained from the patient’s mother.

CASE DESCRIPTION

A 26-year-old male (height 174 cm, weight 88.4 kg, body surface area [BSA] 2.03 m2) with no medical history was admitted to the hospital due to pneumonia complicated by sepsis following failed outpatient fluoroquinolone therapy. Over the course of the first 48 hours, he developed progressive ARDS and worsening septic shock, necessitating the use of multiple vasopressors (initially moderate doses of norepinephrine and vasopressin). A bronchoalveolar lavage on hospital day (HD) 2 indicated the presence of Blastomyces dermatitidis/gilchristii. Liposomal amphotericin B was added to his empiric itraconazole treatment.

Given his hemodynamic instability and an initial echocardiogram revealing a severely dilated and dysfunctional RV, the patient was brought to the operating room (OR) on HD 4 for VV-ECMO cannulation with a 31-French dual-lumen cannula, but he developed severe biventricular dysfunction (left ventricular ejection fraction [LVEF] 10%) and was converted to central VA-ECMO rather than VV-ECMO. After median sternotomy, a 22-French arterial cannula was placed in the aortic arch and 36-French right-angle venous cannula was placed in the RA. Circulatory and oxygenation support was achieved with a Cardiohelp device (MAQUET Holding B.V. & Co KG, Rastatt, Germany). He continued to require moderate doses of dual vasopressor therapy to maintain adequate mean arterial pressure. He developed acute renal failure due to acute tubular necrosis requiring continuous renal replacement therapy. Anticoagulation was initiated with bivalirudin with a goal antithromboplastin time of 60–80 seconds.

After 48 hours of VA-ECMO support, some recovery of LV systolic function was evident on echocardiography (LVEF had risen to 30%). However, systemic oxygen concentration had begun to decline (partial pressure of oxygen [Po2] in arterial blood of 43 mm Hg despite full support) due to increased native cardiac output of deoxygenated blood exceeding circuit flow. Attempts were made to better match native cardiac output to ECMO flow, including increasing ECMO flow rates though without success. Ultimately, the patient was brought back to the OR on HD 6 for arterial cannula repositioning to the proximal ascending aorta. Unfortunately, despite a more proximal positioning, oxygen content of the proximal aorta continued to be suboptimal, so a separate arterial limb was created via a “Y” connector with 22-French arterial cannula to the left PA. On HD 11, due to further left ventricular function recovery, this was converted to a typical RVAD configuration (RA to PA), and his chest was closed. At this juncture, he continued to require low-dose norepinephrine and vasopressin therapy, but his LVEF had improved to 65%.

As his necrotic pulmonary process evolved, the patient developed extensive intrapulmonary shunting with elevated echocardiogram-derived cardiac output of 7.5 L/min. Maximum ECMO flows were 4.9 L/min (limited by an outlet pressure of 400 mm Hg and cannula size), which was insufficient to match his oxygen requirements resulting in hypoxemia. Therefore, 2 possible solutions emerged: (1) the addition of a secondary arterial limb circuit to a systemic artery; and (2) the addition of a percutaneous RVAD to the right PA (not cannulated by the surgical arterial limb). The latter option was selected, in part to avoid repeat sternotomy. On HD 32, a 31-French dual-lumen cannula (Protek Duo cannula; CardiacAssist, Inc, Pittsburgh, PA) was percutaneously placed via the right internal jugular vein and positioned with the tip in the main PA (Figure 1). This cannula was connected to a second Cardiohelp system. With flow through the second Cardiohelp system of 3.5 L/min, complete oxygenation of the large effective venous return was achieved (Figure 2). Anticoagulation regimen did not change. His vasopressor needs were eliminated.

Figure 1.
Figure 1.:
Illustration of configuration of dual RVAD-ECMO circuits. Parallel RVAD-ECMO circuits are shown with individual oxygenator configuration. A surgical venous cannula primarily drained the inferior vena cava, while the percutaneous transjugular catheter venous port primarily drained the superior vena cava. Because of the obligate orientation of the percutaneous catheter toward the right pulmonary artery, the surgical arterial cannula placed in the pulmonary trunk was oriented toward the left pulmonary artery to provide similar perfusion to both lungs. ECMO indicates extracorporeal membrane oxygenation; RVAD, right ventricular assist device. Used with permission of Mayo Foundation for Medical Education and Research. All rights reserved.
Figure 2.
Figure 2.:
Total circuit flow and RPM over time. Total circuit flow and RPM of single ECMO circuit and later dual ECMO circuits plotted over time for the first 10 wk after cannulation. Important mechanical support–related clinical events are highlighted. ECMO indicates extracorporeal membrane oxygenation; PA, pulmonary artery; RPM, revolutions per minute; RVAD, right ventricular assist device; VA, venoarterial.

With improved DO2, hypoxemia improved, and the patient eventually was able to participate meaningfully in rehabilitation. He required a protracted course on ECMO to clear the Blastomyces infection as a bridge to pulmonary recovery or transplant listing. He required 4 oxygenator exchanges over this period. On HD 84, the patient was listed for transplantation. He underwent combined cardiac, pulmonary, and renal transplantation from a single donor on HD 151. Unfortunately, the patient succumbed 36 days after combined transplant due to overwhelming sepsis.

DISCUSSION

We report the successful use of dual VA-ECMO circuits (ELSO configuration: VRA − APA\(dl)V − P), with both surgical and percutaneous RVAD circuits with oxygenator to support hemodynamics and facilitate recovery.

In cardiogenic shock supported with peripheral ECMO, cerebral hypoxemia may develop, in which case direct venous oxygenation via an oxygenated return limb to the RA or PA, so-called V-AV ECMO, mitigates cerebral hypoxemia.5 In respiratory failure, including ARDS, addition of an arterial limb may facilitate improved hemodynamics in a similar V-VA configuration when hemodynamic support is required, such as in severe RV failure.6 While associated with the inherent risks of additional cannulation, V-AV strategy when appropriately selected has shown similar or better outcomes to VV- and VA-ECMO.7

However, in this case, several factors influenced the decision to proceed with ultimate dual cannulation configuration. The initial VA-ECMO support provided complete cardiopulmonary support; thus, if biventricular dysfunction had persisted, and pulmonary flow was minimal, there would have been no need for an additional pulmonary arterial limb. With the simultaneous development of both severe ventilation-perfusion mismatch/shunt due to necrotizing lung infection together with ventricular recovery, the maximum flows with the VRA− APA configuration were limited by high arterial outflow pressures. Because the chest had already been closed, the risk of resternotomy for cannulation reconfiguration was high, particularly in light of possible future transplantation. Therefore, the addition of a second, percutaneous ECMO circuit provided the appropriate DO2.

We describe the first successful use of dual central and percutaneous RVAD-ECMO circuits for the treatment of combined refractory hypoxemia and cardiogenic shock, highlighting the clinical decision-making, advantages, and feasibility of the dual-circuit approach. While the complexity of this approach precludes widespread adoption in cardiopulmonary failure, we demonstrate here that in rare instances in which excessive pulmonary shunting combined with RV failure in a young patient with high metabolic demand results in unacceptable hypoxemia, a dual-circuit physiology may yield improved outcomes on ECMO support.

DISCLOSURES

Name: Andrew N. Rosenbaum, MD.

Contribution: This author helped with conception or design of the work; acquisition, analysis, and interpretation of data for the work; drafting the work and revising it for important intellectual content; and final approval of the version to be published.

Name: John K. Bohman, MD.

Contribution: This author helped with conception or design of the work; revising the work for important intellectual content; and final approval of the version to be published.

Name: Kent H. Rehfeldt, MD.

Contribution: This author helped with conception or design of the work; revising the work for important intellectual content; and final approval of the version to be published.

Name: John M. Stulak, MD.

Contribution: This author helped with revising the work for important intellectual content and final approval of the version to be published.

Name: Richard C. Daly, MD.

Contribution: This author helped with revising the work for important intellectual content and final approval of the version to be published.

Name: Allan M. Klompas, MBBCh, BAO.

Contribution: This author helped with conception or design of the work; revising the work for important intellectual content; and final approval of the version to be published.

Name: Atta Behfar, MD, PhD.

Contribution: This author helped with conception or design of the work; revising the work for important intellectual content; and final approval of the version to be published.

Name: Suraj M. Yalamuri, MD.

Contribution: This author helped with conception or design of the work; acquisition, analysis, and interpretation of data for the work; drafting the work and revising it for important intellectual content; and final approval of the version to be published.

This manuscript was handled by: Markus M. Luedi, MD, MBA.

GLOSSARY

ARDS = acute respiratory distress syndrome

BSA = body surface area

DO2 = delivery of oxygen

ELSO = Extracorporeal Life Support Organization

HD = hospital day

HIPAA = Health Insurance Portability and Accountability Act

LV = left ventricle

LVEF = left ventricular ejection fraction

OR = operating room

PA = pulmonary artery

Po2 = partial pressure of oxygen

RA = right atrium

RPM = revolutions per minute

RV = right ventricle

RVAD = right ventricular assist device

=

VA-ECMO = venoarterial extracorporeal membrane oxygenation

VV-ECMO = venovenous extracorporeal membrane oxygenation

REFERENCES

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3. Lim HS, Howell N, Ranasinghe AExtracorporeal life support: physiological concepts and clinical outcomes. J Card Fail. 2017;23:181196.
4. Broman LM, Taccone FS, Lorusso R, et al.The ELSO Maastricht Treaty for ECLS Nomenclature: abbreviations for cannulation configuration in extracorporeal life support - a position paper of the extracorporeal life support organization. Crit Care. 2019;23:36.
5. Napp LC, Bauersachs JTriple cannulation ECMO, extracorporeal membrane oxygenation: advances in therapy. IntechOpen2016. Available at: https://www.intechopen.com/books/extracorporeal-membrane-oxygenation-advances-in-therapy/triple-cannulation-ecmo.
6. Ius F, Sommer W, Tudorache I, et al.Veno-veno-arterial extracorporeal membrane oxygenation for respiratory failure with severe haemodynamic impairment: technique and early outcomes. Interact Cardiovasc Thorac Surg. 2015;20:761767.
7. Stöhr F, Emmert MY, Lachat ML, et al.Extracorporeal membrane oxygenation for acute respiratory distress syndrome: is the configuration mode an important predictor for the outcome? Interact Cardiovasc Thorac Surg. 2011;12:676680.
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