Percutaneous Pulmonary Venting Via Jugular Vein While On Peripheral ECMO Running
Antonio Loforte, Massimo Baiocchi, Mauro Biffi, Erika Dal Checco, Giuliano Jafrancesco, Francesco Grigioni, Guido Frascaroli, Roberto Di Bartolomeo, Giuseppe Marinelli.
S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy.
OBJECTIVE: Peripheral Extracororeal Membrane Oxygenation (ECMO) setting remains a valid option to treat the cardiogenick shock (CS). We investigated a novel percutaneous approach to unload the left ventricle while on veno-arterial (v-a) femoro-femoral ECMO support.
METHODS: In December 2016, two patients (1 male,59-year-old and 1 female,40-year-old) suffered refractory CS due to primary graft failure after heart transplantation and acute myocarditits, respectively. After a multidisciplinary shock team discussion, it was decided to proceed with percutaneous femoro-femoral v-a ECMO placement and percutaneous left ventricle (LV) venting with Bio-Medicus NextGen (Medtronic) cannula via right internal jugular (IJ) vein access to reach and drain the main pulmonary artery (PA), in the Hybrid Operating Room (OR). Femoral cannulation was performed traditionally via Seldinger technique by usage of DLP Bio-Medicus (Medtronic) cannulae (21Fr, venous drainage and 19Fr, arterial return) in both patients. The PLS with Quadrox D oxygenator (Maquet) circuit was connected to the cannualae and the pump system (Levitronix CentriMag in 1 and Cardiohelp in 1, respectively). A right IJ venous access was established using direct ultrasound visualization. A Lunderquist guidewire (Cook) was advanced under fluoroscopic guidance into the right atrium. A 15Fr Bio-Medicus NextGen (Medtronic) cannula was then advanced over the Lunderquist wire with its distal tip positioned at the level of tricuspidal valve. The Lunderquist wire was removed and a Swan Ganz catheter was advanced into the Bio-Medicus cannula with its distal tip positioned in the main PA. The cannula was then advanced over the Swan Ganz catheter to get the PA too. The Swan Ganz catherer was removed and the cannula connected through a ‘y’ line to the ECMO circuit.
RESULTS: ECMO support time in the two cases was 5 and 8 days, respectively. Both patients were successfully weaned from ECMO since full recovery of myocardial function and the ECMO explanted in the intensive care unit. No ECMO related adverse events occurred.
CONCLUSIONS: The use of v-a femoro-femoral ECMO support associated with PA drainage via IJ vein enables the rapid onset of extracorporeal life support with an effective biventricular unloading. The hybrid OR might be the correct location for appropriate cannulae placement.
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