Right Ventricular Assist Device With Extracorporeal Membrane Oxygenation for Bridging Right Ventricular Heart Failure to Lung Transplantation: A Single-Center Case Series and Literature Review

Abstract

BackgroundRight ventricular heart failure (RVHF) is a critical complication in patients with respiratory failure particularly among those who transitioned to lung transplantation using veno-venous (V-V) extracorporeal membrane oxygenation (ECMO). In these patients, both cardiac and respiratory functions are supported using veno-arterial (V-A) or veno-arterial-venous (V-AV) ECMO. However, these modalities increase the risk of device-related complications, such as thromboembolism, bleeding, and limb ischemia, and they may disturb early rehabilitation. Due to these limitations, a right ventricular assist device with an oxygenator (Oxy-RVAD) using ECMO may be considered for patients with RVHF with V-V ECMO. MethodsThe study included patients who underwent Oxy-RVAD using ECMO due to RVHF while on V-V ECMO as a bridge to lung transplantation (BTT) due to severe respiratory failure. The patients were enrolled at a tertiary care, university hospital between 2018 and 2020. ResultsEight patients underwent Oxy-RVAD using ECMO due to RVHF for BTT. Seven patients were bridged successfully to lung transplantation. One patient died prior to transplantation from complications of interstitial lung disease. There were no major ECMO-related complications during the Oxy-RVAD using ECMO period in any patient. For those patients who were successfully bridged, the average duration of V-V ECMO was 10 days and Oxy-RVAD using ECMO was 12 days. All patients with BTT were discharged with a 30-day survival rate of 100% (7/7 patients). The 180-day survival rate was 85% (6/7 patients). ConclusionsThis study suggests that Oxy-RVAD using ECMO may be a viable option for bridging patients with RVHF to lung transplantation.

Outcomes of Lung Transplantation in Patients With Right Ventricular Dysfunction: A Single-Center Retrospective Analysis Comparing ECMO Configurations in a Bridge-to-Transplant Setting

“…The complication rate was the lowest (37.1%) in the V-V ECMO group and the highest (78.6%) in the V-A/V-AV or Oxy-RVAD group (p = 0.029). Preoperative ECMO duration was similar between the V-A/V-AV ECMO or Oxy-RVAD and configuration change groups (16 [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30] vs. 17 [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]). The median duration from starting ECMO to changing the configuration was 7 days [4.3-62.0 days] in the configuration change group.…”

“…The choice between Oxy-RVAD and V-A ECMO for patients with hemodynamic decompensated RV dysfunction is currently dependent on hospital or physician preference, although the application of Oxy-RVAD is increasing [ 16 ]. Oxy-RVAD, requiring left anterior thoracotomy for the placement of the reinfusion cannula in the pulmonary artery, is technically more complex than peripheral V-A ECMO, but it offers several advantages over V-A ECMO, such as enabling systemic circulation with oxygenated blood and showing fewer thromboembolic complications [ 6 , 9 ]. It also facilitates rehabilitation similar to central V-A ECMO [ 6 , 18 , 25 ].…”

“…When patients on the waiting list develop respiratory failure, they are intubated, started on mechanical ventilation, and uplisted to status 0. If oxygenation and ventilation cannot be maintained by mechanical ventilation alone, and if patients are hemodynamically stable, V-V ECMO is then used [ 9 ]. In our center, the right femoral-right internal jugular vein was mainly selected for V-V ECMO configuration.…”

“…Research comparing the outcomes of different ECMO configurations in patients with RV dysfunction is limited, and there is no established study on when to initiate V-A ECMO. Also, it is well reported that V-A ECMO can present more complications than V-V ECMO, including a heightened risk of bleeding issues such as surgical site, abdominal, and retroperitoneal hemorrhages, as well as potentially devastating complications, such as systemic thromboembolism-related neurological complications, and limb ischemia [ 9 , 10 ]. Therefore, the present study aimed to (1) evaluate the lung transplantation outcomes of BTT patients with RV dysfunction, focusing on their specific ECMO configurations, and (2) identify characteristics including timing, lactic acid levels, and vasoactive inotropic doses when initiating V-A ECMO or RV assist devices with an oxygenator (Oxy-RVAD) in patients with RV dysfunction.…”

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

“…Additionally, the initiation of ECMO using a dual lumen cannula placed via the internal jugular vein has allowed for selected candidates to receive needed physical therapy and ambulate prior to transplantation [ 215 , 216 ]. In addition to pulmonary support via ECMO, other end-organ support such as invasive RRT and ventricular assist devices may be utilized in candidates where dual organ transplantation is being considered (i.e., heart–lung or lung–kidney) [ 217 , 218 , 219 , 220 ]. As these therapies must be employed in the ICU setting, the modern intensivist must be facile with their use.…”