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Ann Thorac Surg 1998;66:1468
© 1998 The Society of Thoracic Surgeons

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Correspondence

Reply

^a Pediatric Intensive Care Unit, Department of Neonatology and Pediatric Intensive Care, University’s Children Hospital, Währinger Gürtel 18, A-1090 Vienna, Austria

To the Editor

We appreciate the comments of Hisatomi and coauthors, reporting the successful preoperative, intraoperative, and postoperative application of venovenous extracorporeal membrane oxygenation (ECMO) in an infant with cyanotic congenital heart disease, whose eventual death was not related to ECMO therapy.

Hisatomi and associates stated that using a double-lumen cannula could help to avoid hemodynamic changes induced by single-lumen cannula tidal-flow venovenous ECMO, as described by our group [1]. As they addressed, a moderate swinging of right atrial pressure is common during AREC (assistence respiratoire extra-corporelle) application. However, if venous filling is adequate (central venous pressure >8 cm H₂O) and tidal flow volume does not exceed 12 mL/kg body weight, the effect of this feature on systemic arterial pressure, even in left ventricular function impairment, is minimal (<5 mm Hg), measured by Sterile Tubing Doppler Flowmeter (Transonic, Ithaca, NY).

We think that the single-lumen cannula provides at least two advantages: first, it enables a smaller (percutaneously applicable) cannula for venovenous ECMO (10F in a term newborn and even 8F in a small neonate), and second, the risk of malposition is evidently decreased. The unrestricted access of blood to the large, circularly positioned holes of the cannula’s tip (Bio-Medicus Pediatric Venous Cannula, Medtronic, Anaheim, CA) prevents impaired venous drainage into the circuit induced by malposition. The Extracorporeal Life Support Organization registry reports frequent need for cannula reposition during ECMO, especially venovenous ECMO (usually performed with a double-lumen cannula) [2].

We had experienced significant problems with ECMO blood flow obstruction, either because of spontaneous positional changing of the cannula or after a collapse of the connective tube of the cannula (to the circuit), especially when using the double-lumen 12F cannula (Jostra, Hirrlingen, Germany). High flow resistance against venous drainage into the ECMO circuit of the 12F double lumen cannula is at least partially responsible: resistance of a 12F double-lumen cannula is more than fourfold greater than that of the 12F single-lumen cannula! In 32 AREC therapies in our unit, only three cannula repositions were necessary (one for replacement of an 8F cannula by a 10F cannula and two because of inadvertent extractive dislocation of the cannula).

Hisatomi and colleagues stressed the advantage of an already existing double-lumen catheter if hemofiltration after ECMO is necessary. We agree principally. However, a high incidence of inevitable hemofiltration during cardiac ECMO has been reported [3]. In case of continuing renal failure after ECMO therapy, a Tenkhoff catheter (Curl Cath Peritoneal Catheter; Quinton Instrument Co, Bothell, WA) is implanted for peritoneal dialysis in our unit. The advantages are safe and easy management in the newborn and no need for anticoagulation. If continued renal failure after ECMO therapy necessitates hemofiltration, we remove the jugular cannula (and the carotid cannula in venoarterial ECMO) and insert a 5F Pediatric Double Lumen Catheter (Medical Components Inc, Harleysville, PA) into the femoral vein for pump-assisted venovenous continuous hemofiltration or hemodiafiltration (AK 10 Blood Monitor; Gambro, Lund, Sweden). That enables unimpaired cerebral perfusion as soon as possible.

Finally, the AREC system, like other nonocclusive systems, is safer than occlusive systems because it reduces the risk of raceway rupture and gas embolism [4].

We appreciate that Hisatomi and colleagues have presented a further report of successful perioperative venovenous ECMO in cyanotic congenital heart disease.

References

1. Trittenwein G., Fürst G., Golej J., et al. Preoperative ECMO in congenital cyanotic heart disease using the AREC system. Ann Thorac Surg 1997;63:1298-1302.[Abstract/Free Full Text]
2. Zwischenberger J.B., Upp J.R. Emergencies during extracorporeal membrane oxygenation and their management. In: Zwischenberger J.B., Bartlett R.H., eds. ECMO, extracorporeal cardiopulmonary support in critical care. Ann Arbor: Extracorporeal Life Support Organization, 1995:221-249.
3. Fasules J.W. Extracorporeal life support for infants and children with cardiac disease. In: Zwischenberger J.B., Bartlett R.H., eds. ECMO, extracorporeal cardiopulmonary support in critical care. Ann Arbor: Extracorporeal Life Support Organization, 1995:445-471.
4. Chevalier J.Y., Couprie C., Larroquet M., Renolleau S., Durandy Y., Costil J. Venovenous single lumen cannula extracorporeal lung support in neonates: A five year experience. ASAIO J 1993;39:M654-M658.[Medline]

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