Jordan Feltes, MD
George Washington Unversity
Washington, District of Columbia
Disclosure information not submitted.
Riad Akkari, MD
Critical Care Fellow
George Washington University
Laurel, MD
Disclosure information not submitted.
Robert Markie, RN
ECMO Coordinator
George Washington University Hospital, United States
Disclosure information not submitted.
Salim Aziz, MD
professor of Heart Surgery
George Washington University Hospital, United States
Disclosure information not submitted.
David Yamane, BS, MD
Assistant Professor of Emergency Medicine, Anesthesiology, and Critical Care Medicine
George Washington University Hospital, United States
Disclosure information not submitted.
Mustafa Al-mashat, MD
Assistant professor
George Washington University, United States
Disclosure information not submitted.
Title: “Double ECMO”: A Centrally Cannulated VVA-A Solution for BiVAD Failure
Case Report Body
Introduction: Thrombosis within a Ventricular Assist Device (VAD) circuit is a common and life-threatening complication. Typical troubleshooting options include fluid challenge, increasing systemic anticoagulation, catheter-directed thrombolysis, and VAD replacement. In this case, we describe the use of a novel technique for converting an existing BiVAD into a modified centrally cannulated veno-arterial ECMO circuit with double oxygenators in the setting of thrombosis of the original circuit and shock refractory to medical management.
Description: A 71-year-old female with a history of rheumatic heart disease and prior aortic and mitral valve replacements presented to an outside hospital with fatigue and hematuria from hemolytic anemia related to her mechanical valves. She was transferred for cardiothoracic surgery evaluation and underwent replacement of mitral, aortic, and tricuspid valves. Her intra-operative course was complicated by failure to transition off cardiopulmonary bypass due to poor cardiac function ultimately requiring BiVAD. The patient’s postoperative recovery was further complicated by acidosis, elevated vasopressor requirement, and on postoperative day four, her BiVAD flows decreased leading to hypotension despite aggressive resuscitation, concerning for pump thrombosis. In lieu of the critical BiVAD failure, the decision was made to convert the BiVAD configuration to a centrally cannulated ECMO circuit, created by anastomosis of the drains from superior and inferior vena cavas, pulmonary artery, and left atrium as inputs with return flow to the aorta via two oxygenators. The patient transiently recovered with noted improvement in her laboratory results and a decrease in her vasopressor requirements. However, her hospital course was further complicated by renal failure, liver failure, and fulminant diffuse intravascular coagulation leading to circuit thrombosis despite anticoagulation. The family eventually made the decision to terminate ECMO and allow the patient to return to her natural state.
Discussion: Pump thrombosis is a potentially life-threatening complication of VADs. In rare cases, we present the use of “VVA-A ECMO” with flow reconfigurations as an option for BiVAD failure.