Reducing the Risk of Cardiac Perforation During Placement of Bicaval Veno-Venous Extracorporeal Membrane Oxygenation Cannulae

Abstract

Cannula placement for veno-venous extracorporeal membrane oxygenation (VV-ECMO) is not without risk, and cannulation-associated complications can result in significant patient harm.1Kessler A. Coker B. Townsley M. Zaky A. Extracorporeal membrane oxygenator rotational cannula catastrophe: A role of echocardiography in rescue.J Cardiothorac Vasc Anesth. 2016; 30: 720-724Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar The letter by Banayan et al demonstrates the catastrophic consequences of cardiac perforation during dual lumen bicaval cannula placement, but the true incidence of this complication remains unknown.2Banayan J.M. Barry A. Chaney M.A. Right ventricular rupture during insertion of an Avalon Elite(®) catheter.J Cardiothorac Vasc Anesth. 2016; 30: e34-e35Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Echocardiography plays a key role in confirming guidewire placement, and its utility with regards reducing the incidence of cardiac perforation is widely accepted.3Extracorporeal Life Support Organization. Ultrasound guidance for extra-corporeal membrane oxygenation veno-venous ECMO specific guidelines. Available at: 〈https://www.elso.org/Portals/0/Files/elso_Ultrasoundguidance_vvecmo_guidelines_MAY2015.pdf〉. Accessed August 31, 2017.Google Scholar Despite this, we believe that additional steps can be taken to reduce the absolute occurrence of cardiac perforation during dual lumen bicaval VV-ECMO cannula placement. The 2015 Extracorporeal Life Support Organization guidelines state that echocardiographic guidance of bicaval dual lumen cannula placement is an alternative to fluoroscopic guidance, but the approach used should depend on the expertise available at individual institutions. Furthermore, it is stated that real-time echocardiographic guidance during insertion will prevent cardiac perforation. We believe, however, that the risk of cardiac perforation can only be completely avoided through the additional use of stiff guidewires in combination with fluoroscopic imaging and the selection of alternative cannulation sites when fluoroscopy is not available. Stiff guidewires have long been used for interventional cardiology procedures to safely deploy percutaneous intravascular or intracardiac devices. Nevertheless, most VV-ECMO cannula insertion packages contain soft, flexible guidewires. We believe that this lack of rigidity can sometimes result in intravascular or intracardiac looping that directs dilators and cannula toward the wall of the right ventricle, thus greatly increasing the risk of cardiac perforation. A rigid guidewire can prevent looping and therefore greatly reduce the risk of cardiac perforation. This must be offset, however, against the increased risk of direct harm caused by the stiffer, more rigid guidewire. Intravascular and intracardiac looping also can be visualized with fluoroscopy, as can other forms of malplacement, and therefore it should be used when available. Fluoroscopic imaging can be used to safely position wires, dilators, and cannulae toward their intended targets, and if this imaging modality is not available, we advocate for jugular-femoral or bifemoral cannulation as a safe alternative. We therefore believe that the 2015 Extracorporeal Life Support Organization guidelines for VV-ECMO cannula placement require updating in view of the added safety that fluoroscopy offers for the insertion of jugular bicaval cannulae. We also call for manufacturers to consider increasing the rigidity/stiffness of wires included with VV-ECMO cannula insertion packages. Despite these recommendations and despite adequate training and experience among operators, it is likely that cannulation for VV-ECMO will remain a high-risk procedure in any institution.