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Abstract

Introduction: Percutaneous instrumentation on a patient with the total artificial heart (TAH) is challenging due to the presence of a mechanical valve in the tricuspid position. Any upper extremity wiring requires extreme caution to avoid violating the mechanical valve. We report a case of unique utilization of a single bi-caval Avalon cannula (Maquet, Rastatt, Germany) for venovenous (VV) extracorporeal membrane oxygenation (ECMO) in a patient on TAH. A 22-year-old female with a dilated cardiomyopathy developed cardiogenic shock complicated by acute renal, liver, and respiratory failure. She was placed on venoarterial (VA) ECMO for bridge to decision. During VA ECMO support, her condition was stabilized with continuous venovenous hemodialysis (CVVHD), molecular adsorbents recirculation system, and ARDSnet ventilator protocol. The patient failed to wean from VA ECMO due to severe biventricular failure and we placed the TAH (SynCardia, Tucson, AZ). During the TAH implantation, the patient developed severe respiratory failure, presumably from significant alveolar leak secondary to massive fluid and blood resuscitation. The patient was placed on VV ECMO for oxygenation and ventilation. A single bi-caval Avalon cannula was placed in the right internal jugular (IJ) vein percutaneously and the position was confirmed by intraoperative transesophageal echocardiography and palpation within the operative field. The cannula tip was fixed in the inferior vena cava using a vessel loop to prevent migration into the TAH. VV ECMO flow was ~4 L/min and improved oxygenation/ventilation remarkably without further intervention. CVVHD was initiated in the ICU for fluid control. After 12 days weaning VV ECMO, the IJ cannula was removed. However, the patient quickly developed a significant respiratory acidosis; thus, another Avalon cannula was placed in the iliac vein via femoral access for CO2 clearance only. Our pulmonologist optimized lung recruitment and ventilator management while VV ECMO was weaned. The cannula was removed after 10 day of support. The ventilator was weaned and she was cycled on and off trachostomy collar. After 96 days the patient tolerated no ventilator support and she had a clear chest radiograph. Post-operative day 104 she received an orthotopic heart transplant.