Ann Thorac Surg 2011;91:1996-1997. doi:10.1016/j.athoracsur.2011.01.005
© 2011 The Society of Thoracic Surgeons
How To Do It
Extracorporeal Membranous Oxygenation and Left Atrial Decompression: A Fast and Minimally Invasive Approach
Virginie Fouilloux, MD*,
Lionel Lebrun,
Loic Macé, MD, PhD,
Bernard Kreitmann, MD, PhD
Department of Thoracic and Cardio-vascular Surgery, Paediatric Cardiology, Timone Children's Hospital, Marseille, France
Accepted for publication January 3, 2011.
* Address correspondence to Dr Fouilloux, Chirurgie Thoracique et Cardio-vasculaire Hôpital D'enfants de la Timone, 265, rue Saint-Pierre, Marseille, 13 385 France (Email: virginie.fouilloux{at}ap-hm.fr).
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Abstract
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Left atrial decompression for patients under extracorporeal membranous oxygenation is sometimes mandatory, but it may be technically difficult. We describe a safe and minimally invasive technique to perform this while placing a small cannula antegradely in the pulmonary artery trunk.
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Introduction
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Extracorporeal membranous oxygenation (ECMO) is now commonly used in adult and pediatric intensive care units for circulatory and respiratory support. Peripheral ECMO is frequently used without any thoracotomy. If the myocardial function is impaired, the left ventricle is sometimes unable to eject the pulmonary backflow, causing dilatation of the left atrium and pulmonary edema. This very serious problem has to be managed with a left atrial decompression (vent).
To avoid a thoracotomy and mobilization of a thrombus located in the left atrium, we recently chose to unload the left ventricle with a cannula inserted in the pulmonary trunk through the inferior vena cava with a femoral approach. We report this very successful procedure.
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Technique
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Clinical Summary
A 2-year-old girl was transferred to our institution with a restrictive cardiomyopathy 2 weeks after a stroke, which led to the diagnosis. A transthoracic echocardiography showed severely decreased cardiac function and a large thrombus inside the left atrium. The patient was placed on the list for cardiac transplantation, but her situation rapidly declined. She was then transferred to the intensive care unit with very poor hemodynamics, and subsequent ventricular tachycardia. An arteriovenous ECMO (oxygenator Sorin D902; Sorin Group, Le Plessis Robinson, Paris, France) with neck vessels cannulation was started with a 12-French arterial cannula and a 14-French venous cannula. A few hours later, hemic tracheal aspirations, and a chest roentgenogram showed an acute pulmonary edema (Fig 1
). A transthoracic echocardiography confirmed the huge dilatation of the left atrium. The persistent large atrial thrombus was viewed as a contraindication to perform a percutaneous atrial septostomy or to put a vent in the left atrium with a sternotomy or a lateral thoracotomy. We decided to place a venting cannula in the pulmonary trunk.
Technique
In the catheterization laboratory, an attempt to percutaneously approach the right femoral vein failed, and the vessel was surgically exposed with a short skin incision. A guidewire (Platinum Plus 0.014 inches [Boston Scientific, Natick, MA]) was inserted in the femoral vein and placed in the pulmonary trunk and the left pulmonary artery. A 10-French cannula (left heart vent catheter, ref 12110 [Medtronic DLP; Medtronic, Fourniies, France]), usually used during open heart surgery, was inserted over the wire and pushed until it reached the left pulmonary artery. Normally, the end of this vent catheter is not open, so it was necessary to create a small opening for the guidewire. The whole procedure was controlled by radio guidance (Fig 2
). There was no complication during the procedure. This pulmonary line was connected to the ECMO venous line with a "Y" connector. No other change was made on the ECMO circuit. A few hours later, the chest roentgenogram improved and the tracheal aspirations became clear. A transthoracic echocardiography showed the same left thrombus dramatically and a very evident unloaded left heart. Five days later, recovery of the left ventricular function allowed weaning of this "femoral venting." The cannula was removed. There was no clot or thrombosis on the wall of the cannula. The femoral vein was repaired and Doppler echocardiogram showed good permeability in the early follow-up. There was no clinical or echographical sign of pulmonary emboli. The left thrombus resolved gradually and 21 days later the patient had biventricular assist device placement. During surgery, no adverse effect of the pulmonary artery vent and no left thromboses were seen. The patient was extubated and was well as possible, while waiting for a transplant.
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Fig 2. The procedure controlled by radio guidance, showing the vent in the left pulmonary artery (arrow).
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Comment
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Although sometimes a life saving and mandatory matter, the management of left heart unloading in a patient with ECMO is not very often discussed in the literature [1]. Usually, when needed, a left vent is placed in the left atrium through the right superior pulmonary vein. This procedure requires a thoracotomy, at least minimally invasive [2], even in case of peripheral ECMO. Hemostasis and infectious complications of the surgical approach may increase morbidity. Peripheral ECMO, being the procedure of choice in most institutions [3], and left side venting is usually managed by percutaneous balloon atrial septectomy [4–7].
We believe that left atrial decompression through the pulmonary trunk during ECMO has never been described; however, even if this was described, especially in redo procedures, it has often been used during open cardiac procedures. When the pericardial adhesions make hazardous to expose the atrial groove, a vent is directly placed through the anterior wall of the pulmonary artery. This retrograde venting of pulmonary flow empties the left atrium as effectively as usual venting. This practice led us to solve the problem raised by this case, which because of the left thrombus, the endovascular approach through the atrial septum was believed to be unsafe, as well as the direct surgical procedure.
Retrograde venting of the pulmonary backflow through the femoral vein and the pulmonary trunk is an alternative method that avoids sternotomy, hemorrhagic, and infectious complication, and seems to be greatly effective. In this case, the small weight of the patient (10 kg) added a technical difficulty. The femoral venous cannula smaller than the 16-French was not available, so we diverted the use of the 10-French Medtronic DLP cannula (Medtronic, Fourniies, France), which is used in infant open heart procedures. The difference in diameter between this venting cannula and the venous one (10-French vs 14-French, respectively), presumably regulated the left side suction, as no collapse of the pulmonary arterial wall was noted during the whole period of venting.
In conclusion, retrograde unloading of the left atrium and ventricle through the pulmonary trunk and the femoral vein is an original procedure, which can be very useful during ECMO. It is minimally invasive, safe, and effective. The good outcome of this case may be replicated in similar situations, if needed, and this may inspire medical device firms to design specific cannulas.
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References
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- Hanna BD. Left atrial decompression: is there a standard during extracorporeal support of the failing heart? Crit Care Med 2006;34:2688-2689.[Medline]
- Marelli D, Laks H, Meehan D, Fazio D, Alejos J. Minimally invasive mechanical cardiac support without extracorporeal membrane oxygenation in children awaiting heart transplantation Ann Thorac Surg 1999;68:2320-2323.[Abstract/Free Full Text]
- Del Nido P. Extracorporeal membrane oxygenation for cardiac support in children Ann Thorac Surg 1996;61:336-339.[Abstract/Free Full Text]
- Koenig PR, et al. Balloon atrial septostomy for left ventricular decompression in patients receiving extracorporeal membrane oxygenation for myocardial failure J Pediat 1993;22:S95-S99.
- Mosca R. Balloon atrial septostomy let's take a closer look J Am Coll Cardiol 2009;53:1812-1813.[Medline]
- Hlavacek AM, Atz AM, Bradley SM, Bandisode VM. Left atrial decompression by percutaneous cannula placement while on extracorporeal membrane oxygenation J Thorac Cardiovasc Surg 2005;130:595-596.[Free Full Text]
- Algayran RM, Rocchini AP, Remenapp RT, Graziano JN. Decompression of the left atrium during extracorporeal membrane oxygenation using a transseptal cannula incorporated into the circuit Crit Care Med 2006;34:2603-2606.[Medline]
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Abstract
Introduction
