Transfer Technique From Femoro-Jugular Veno-Venous ECMO to Veno-Pulmonary ECMO With a ProtekDuo Cannula: Step-by-Step

Introduction 

The ProtekDuo double-lumen cannula can be used in different configurations. Normally, it is introduced through the jugular vein for right ventricular assistance, with or without an oxygenator, as seen in veno-pulmonary extracorporeal membrane oxygenator (ECMO) or as a double drainage (1). 
 
Clinical Case  

The authors present a case of a 44-year-old man, without any known relevant history, who was admitted for treatment of a community acquired pneumonia due to streptococcus pyogenes. Within 24 hours it had a poor evolution, causing the patient to develop respiratory insufficiency, septic shock, oligoanuria, and increased lactic acid up to 4.9 mmol/L. The patient was then admitted to the intensive care unit. A cardiac echocardiography revealed global left ventricular hypokinesia and a left ventricular ejection fraction of 20 percent. Due to worsening respiratory insufficiency and refractory hyperlactatemia, it was decided to implant a venous-arterial femoro-axillary ECMO. After 17 days of assistance, however, the surgeons added an inflow jugular cannula due to worsening of hypoxemia and hypercapnia and a white lung radiological pattern. After improvement in left ventricular (LV) function, the axillary cannula was removed, converting the assistance in a venous-venous, femoral-jugular ECMO. After a very slow progressive clinical improvement of the respiratory insufficiency, it was decided to transfer to venous-pulmonary ECMO with a ProtekDuo cannula to improve rehabilitation and recovery of the patient. 

The procedure was performed with fluoroscopy. To begin, the echo guided access of the contralateral femoral vein to the already cannulated vein to place a long non-multifenestrated 19 Fr cannula with the tip at the right atrium. The configuration was then changed from femoral-jugular to femoral-femoral ECMO. Once the jugular canula was clamped and isolated, it was punctured to pass an Extra Stiff Amplatz guide wire (260 cm, 0,035’) to change the canula to a 22 Fr Dryseal Sheath. Through this sheath, a  Radifocus stiff hydrophilic guide wire (150 cm, 0,035’) and a multipurpose (MPA) catheter were placed to navigate through the right atrium and right ventricle to reach the pulmonary artery. The guide wire was then exchanged for a rigid Back-Up Meier guidewire. The Dryseal Sheath was removed, and the guide wire was used to place the double-lumen ProtekDuo cannula. Once again, the configuration of the ECMO was reconnected and changed, to start the venous pulmonary assistance and remove the femoral cannulas. After 15 days of assistance with venous pulmonary ECMO, the patient was taken off assistance without any associated complication. 
 
Conclusion 

The use and implementation of the ProtekDuo cannula is expected to increase due to its clear advantages and ease of placement, which allows for greater mobility and rehabilitation of the patient (2). The ECMO configuration as venous-pulmonary assistance with a ProtekDuo cannula has been used in the authors’ center in four different cases—three as a bridge to recovery of pulmonary function, and one case as a right ventricular assistance with an oxygenator as a bridge to cardiopulmonary transplantation—without any complications in any case. 

References

1. Maybauer MO, Koernes MM, Swol J, et al. The novel ProtekDuo ventricular assist device: configurations, technical aspects, and present evidence. Perfusion 2023; 38: 887-93
2. John KJ, Nabzdyk GCS, Chweich H, et al. ProtekDuo percutaneous ventricular support system-physiology and clinical applications. Anns Transl Med 2024; 12: 14

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