Intraoperative Transesophageal Echocardiography–Guided Placement of Bicaval Dual-Lumen Extracorporeal Membrane Oxygenation Cannula

Abstract

Live imaging with intraoperative transesophageal echocardiography (TEE) is frequently used to guide placement for interventional cardiothoracic procedures. The Avalon Bi-Caval Dual Lumen Catheter (Avalon Laboratories, Rancho Dominguez, CA) can establish venovenous (VV) extracorporeal membrane oxygenation (ECMO) with single cannulation via the right internal jugular vein. The Avalon Bi-Caval Dual Lumen Catheter is a single-cannula VV ECMO system used in patients with isolated severe respiratory failure and preserved cardiac function. Historically, VV ECMO has been achieved using dual cannulation via the jugular and femoral veins.1 Advantages of single-site VV ECMO include increased patient mobility, less site infection, and decreased chance of accidental dislodgement.2 The Avalon cannula has proximal and distal inflow orifices in the superior vena cava and inferior vena cava (IVC) to drain deoxygenated blood (Figure 1). The outflow port is aimed toward the tricuspid valve to deliver oxygenated blood through the valve and into the right ventricle. TEE is used to guide placement of the cannula as well as evaluate the final position and directionality of outflow once VV ECMO has been initiated. Malposition of the cannula may cause low ECMO flow or hypoxia because of recirculation. Despite proper placement, cannula migration into the hepatic vein or right ventricle is possible postoperatively.4 The following case describes the use of TEE to optimize the position of the cannula tip using two-dimensional echocardiography and ensure laminar outflow through the tricuspid valve using color flow Doppler. Open in a separate window Figure 1 Illustration of Avalon Bi-Caval Dual Lumen cannula in correct position.