The University of Michigan Experience with Veno-Venoarterial Hybrid Mode of Extracorporeal Membrane Oxygenation

Abstract

The veno-venoarterial (VVA) mode of extracorporeal membrane oxygenation (ECMO) is defined by having both venous and arterial reinfusion cannulas. It is purposed to improve upper body oxygenation as the venous reinfusion cannula is typically placed in the upper body. We performed a single-center retrospective review to better characterize the patients placed on this mode. Adults (n = 23) were 40.4 ± 14.7 years old and were supported with ECMO for a median of 141 (97, 253) hours, with VVA support 110 (63, 179) hours. Ten (43%) were initially cannulated VVA; reasons for conversion included cardiac failure (46%), North-South syndrome (38%), and worsening hypoxia (15%). Survival was 39% and neurological complications 13%. Pediatrics (n = 8) were 13.0 ± 2.4 years old and were supported with ECMO for a median of 258 (168, 419) hours, with VVA support 131 (98, 161) hours. One (12.5%) was initially cannulated VVA; reasons for conversion were North-South syndrome (42%), cardiac failure (29%), and worsening hypoxia (29%). Survival was 71% and neurological complications 29%. We concluded that there was neither survival advantage nor complication reduction with the VVA mode in this cohort; however, VVA does have value for unique clinical situations when conventional ECMO modes do not meet support needs.

Choosing the appropriate configuration and cannulation strategies for extracorporeal membrane oxygenation: the potential dynamic process of organ support and importance of hybrid modes

“…Patient physiology or clinical conditions and needs, may change over time (e.g. the heart may recover faster than the lungs) and modifications in ECMO configuration mat be occasionally necessary. The conversion from the initial ECMO strategy to a different modality should always be strongly considered if the patient's perfusion is inadequate or other goals of therapy are not being met, or if complications are arising as a result of the cannulation strategy, e.g.…”

“…differential hypoxemia. The need to convert to a different ECMO modality should not necessarily be considered as a planning failure, but rather as a response to a patient's dynamic condition.…”

“…This review will outline different ECMO modes and fundamentals of cannulation strategies to achieve adequate perfusion and effective organ support and recovery, particularly highlighting more complex ECMO patterns, so called “hybrid configuration”, sometimes necessary to overcome ongoing shortcomings or improve ECMO efficiency.…”

Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review

“…Upper body hypoxemia is rarely seen in patients who receive VA-ECMO with axillary artery cannulation. 103,104 Conversion from VA-ECMO to VAV-ECMO involves the addition of a right internal jugular venous cannula. This may be a single-lumen return cannula, or a double-lumen Avalon Elite cannula, which allows for bicaval drainage and right atrial return, with minimal recirculation between inflow and outflow ports.…”

Management strategy during neonatal/paediatric VV ECMO run

“…Reconfiguration of the circuit may prove necessary in some cases and is better done early in the run. 4 Troubleshooting: Protocol and bundle adherence are the keys to preventing complications. Detection requires vigilance and rigorous checks along with comprehensive handover and tight teamwork.…”