Central Cannulation of VA ECMO for Severe Pulmonary Hypertension and Cardiogenic Shock

First Author(s)

• 

  Shruti Shankar, MD,

  Resident
  n/a

  Disclosure information not submitted.

  Slides and Audio

Co-Author(s)

• RR

  Ricardo Restrepo, MD, MSc

  Assistant Professor; Medical Director, Center For Pulmonary Vascular Diseases
  University of South Florida, United States

  Disclosure information not submitted.
• DB

  Debabrata Bandyopadhyay, MD

  Assistant Professor; Director, Interstitial Lung Disease and Sarcoidosis Program
  University of South Florida, United States

  Disclosure information not submitted.
• NS

  Nirmal Sharma, MD

  Assistant Professor; Medical Director, Lung Transplantation Program
  Brigham & Women’s Hospital, United States

  Disclosure information not submitted.
• KP

  Kapilkumar Patel, MD

  Assistant Professor; Director, Center for Advanced Lung Disease and Lung Transplant Program
  University of South Florida, United States

  Disclosure information not submitted.

Title: Central Cannulation of VA-ECMO for Severe Pulmonary Hypertension and Cardiogenic Shock

Case Report Body:

Introduction: Central cannulations of veno-arterial (VA) extracorporeal membranous oxygenation (ECMO) devices are conventionally associated with post-cardiotomy cardiogenic shock. There are several studies with pumpless lung assist devices or peripherally inserted VA-ECMO as a bridge to transplant in those with pulmonary arterial hypertension (PAH) and shock. To our knowledge, centrally cannulated VA-ECMO has not often been used in this setting.

Description: A 29-year-old female with systemic lupus erythematosus and Group 1 PAH presented as a transfer for lung transplant evaluation due to progressive right ventricular (RV) failure despite therapy with milrinone, remodulin IV, ambrisentan, and sildenafil. Echocardiogram showed left ventricular ejection fraction 60-65%, tricuspid annular plane systolic excursion 1.8 cm, and moderate tricuspid regurgitation. Right heart catheterization confirmed mean pulmonary artery pressure 79 mmHg, wedge pressure 16 mmHg, cardiac index (CI) 1.4 L/min/m2, and pulmonary vascular resistance 28 WU. Within 48 hours, she developed progressive multiorgan failure (liver and kidney) despite maximal IV therapy. We decided to centrally cannulate with an angled venous cannula in the left atrium via the right superior pulmonary vein and a two-stage venous cannula in the RA. Peripheral veno-venous (VV) ECMO was initiated for stability during intubation and insertion. She developed side effects to remodulin but was able to tolerate its discontinuation. She remained on VA-ECMO for 5 weeks until successful bilateral lung transplant with normalization of echo findings.

Discussion: Central cannulation allowed for complete bypass of the failing RV and the high resistance of the pulmonary vascular bed, allowing for remodeling. It also avoided the risks of peripheral cannulation such as Harlequin syndrome, immobility, and limb ischemia. VV-ECMO is sometimes used in PAH, often with the creation of an atrial septal defect to offload the RV but is unable to do so completely. Atrial septostomy is also invasive and has shown poor outcomes in patients with end-stage PAH and low CI. In the correct setting, central VA-ECMO could be used in end-stage PAH patients to allow for early remodeling, rather than waiting for this process to occur after transplant.