ECMO and Right Ventricular Failure: Review of the Literature

Abstract

Right ventricular (RV) failure is the inability of the RV to maintain sufficient cardiac output in the setting of adequate preload, due to either intrinsic injury to the RV or increased afterload. Medical treatment of RV failure should include optimizing preload, augmenting contractility with vasopressors and inotropes, and considering inhaled pulmonary vasodilators. However, when medical therapies are insufficient, mechanical circulatory support (MCS) is needed to maintain systemic and RV perfusion. The data on MCS for isolated RV failure are limited, but extracorporeal membrane oxygenation (ECMO) appears to be the most efficient and effective modality. For patients with isolated RV failure from acute hypoxemic respiratory failure, veno-venous (VV) ECMO is an appropriate initial configuration, even if the patient is in shock. With primary RV injury or RV failure with concomitant left ventricle (LV) failure, however, venoarterial (VA) ECMO is indicated. Both modalities provide indirect support to the RV by reducing preload, reducing RV wall tension, and delivering oxygenated blood to the coronary circulation. Peripheral cannulation is required in VV-ECMO and is most commonly used in VA-ECMO, allowing for rapid cannulation even in emergencies. Changes in pulsatility on an arterial catheter waveform can indicate changes in clinical status including changes in myocardial function, inadequate preload, worsening RV failure, and excessive VA-ECMO support leading to an elevated LV afterload. Myocardial function may be improved by titration of inotropes or vasodilators, utilization of an Impella or an intra-aortic balloon counterpulsation support devices, or by changes in VA-ECMO support.

Pediatric and neonatal extracorporeal life support: current state and continuing evolution

“…Double-lumen cannulae are most commonly placed in the internal jugular vein, though they can be placed in the femoral vein in adults and larger pediatric patients. Both drainage and reinfusion occur in or very near to the right atrium, which produces recirculation—a major disadvantage of V–V ECLS [ 81 ]. The effects of recirculation can be minimal or profoundly negative, depending on the patient’s volume status, their cardiac output, and the position of the cannula [ 81 ].…”

“…Both drainage and reinfusion occur in or very near to the right atrium, which produces recirculation—a major disadvantage of V–V ECLS [ 81 ]. The effects of recirculation can be minimal or profoundly negative, depending on the patient’s volume status, their cardiac output, and the position of the cannula [ 81 ]. Additionally, V–V provides no hemodynamic support, as reinfusion occurs in the low-pressure right atrium and passes through the pulmonary circulation before entering the systemic circulation.…”

“…Third, V–V ECLS increases coronary artery blood flow [ 85 ] and oxygen delivery [ 86 ] by increasing the oxygen saturation of native cardiac output, which is the primary source of coronary artery perfusion. Lastly, it avoids the increase in left ventricular afterload that is seen with V–A ECLS [ 81 ].…”

ECMO and POPH: More Help for the Right Heart

“…The use of ECMO must only be used as a bridge in cases with a clearly identified and realist destination. (3) ECMO is a resource-intense therapy, especially so particularly in the current coronavirus disease 2019 pandemic. Barbas et al used periprocedural VA-ECMO as a bridge to weather the typical intraoperative insult on RV hemodynamics during LT (acidosis, rapid changes in RV preload, anesthetic effects, and positive pressure ventilation).…”

“…The use of ECMO must only be used as a bridge in cases with a clearly identified and realist destination 3 . ECMO is a resource-intense therapy, especially so particularly in the current COVID-19 pandemic.…”