Utility of three‐dimensional transesophageal echocardiography to guide transseptal positioning of a single multistage venous cannula to provide both venous drainage and indirect left ventricular venting in veno‐arterial extracorporeal membrane oxygenation

Abstract

A patient with heart failure due to dilated ischemic cardiomyopathy presented in cardiogenic shock for institution of veno‐arterial extracorporeal membrane oxygenation as a bridge to cardiac transplantation. To provide adequate venous drainage and simultaneous decompression of the left atrium (indirect left ventricular venting), a single venous cannula was placed across the interatrial septum so that the distal orifice and side ports were located within the left atrium and the proximal set of side ports were positioned at the cavoatrial junction. Three‐dimensional transesophageal echocardiography demonstrated utility in guiding cannula placement and appropriate positioning within the left atrium.

Utility of transesophageal echocardiography to assess real time left atrial pressure changes and dynamic mitral regurgitation following placement of transseptal multistage venous cannula for systemic venous drainage and indirect left ventricular venting in venoarterial extracorporeal membrane oxygenation

“…The role of LA-VA ECMO as a means of drainage of the left and right heart is established, as is the role of real time TEE in ECMO cannula placement. [1][2][3] To the best of our knowledge, this is the first documentation by TEE of real time reduction in LA pressures as evidenced by resolution of holosystolic flow reversal in the PVs. Our findings demonstrate mechanistic insight into some of the hemodynamic benefits of this single cannula biatrial unloading approach.…”

“…1,2 As we have previously described, three-dimensional (3D) transesophageal echocardiography (TEE) was crucial to guide placement of the cannula in the left atrium (LA). 3 While TEE is an established means of estimating LA filling pressures and severity of MR, this case demonstrates the role of TEE in real time assessment. 4,5 We demonstrate a change in flow pattern from holosystolic flow reversal in the pulmonary veins (PVs) to a small degree of systolic blunting following initiation of LA-VA ECMO, which to the best of our knowledge is a novel finding.…”

Echocardiography for extracorporeal membrane oxygenation

“…55 Several instances of direct percutaneous cannulation of the LA (left atrial veno-arterial [LAVA] ECMO) with a venous cannula as a method of indirect left ventricular venting are now reported in the literature. [56][57][58] As opposed to balloon septostomy, the addition of a drainage cannula allows for adjustment of flow to facilitate more or less unloading of the chamber.…”

“…Color flow Doppler and 3D echocardiography can be used to visualize the flow and the ports in respect to their location in the RA and LA. 3D imaging allows for real time visualization of the cannula and its side ports, the IAS, the LA wall, the RA wall, and the aortic root (Video 25) 56. Upon initiation of LAVA-ECMO, flows can be adjusted with TEE assistance with a goal of AV opening with each cardiac cycle (Video 26) 56.…”

“…3D imaging allows for real time visualization of the cannula and its side ports, the IAS, the LA wall, the RA wall, and the aortic root (Video 25) 56. Upon initiation of LAVA-ECMO, flows can be adjusted with TEE assistance with a goal of AV opening with each cardiac cycle (Video 26) 56. In the case of severe MR, initiation of LAVA-ECMO has been shown to improve pulmonary vein flow reversal as visualized by PWD to at least blunted systolic pulmonary vein flow 58.…”