SINGLE SITE EXPERIENCE WITH TRANSESOPHAGEAL ECHOCARDIOGRAPHIC GUIDANCE OF DUAL LUMEN VENO-VENOUS EXTRACORPOREAL MEMBRANE OXYGENATION CATHETER INSERTION

Abstract

Background: The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) with a dual-lumen (DL) catheter for rescue therapy of pulmonary failure is increasing. Insertion of this catheter via the right internal jugular into the right atrium (RA) and inferior vena cava (IVC) has been described with fluoroscopy and echocardiographic guidance, but there is limited published data on either approach. Our institution has inserted DL VV-ECMO with transesophageal echocardiography (TEE) guidance at the bedside in a critical care setting for five years. Methods: We reviewed all cases of DL VV-ECMO insertion. Data regarding TEE views, imaging technique, and procedural complications were collected from TEE reports, image review, and procedure notes. Results: 47 DL VV-ECMO catheters have been placed at our institution. The vast majority (44/47; 93.6%) were placed using TEE guidance without complication. Two cases required fluoroscopy to confirm wire placement. In one case RA perforation occurred and was immediately recognized by TEE. There were no TEE related complications. Bicaval and deep IVC views established wire and catheter position in the IVC. Various views excluded migration into other structures. Color Doppler confirmed both cannula inflows in the cava and outflow in the RA. Biplane acquisition improved the efficiency and confidence of TEE imaging. Monitoring for complications such as perforation or cannula malposition was critical. Although not formally reviewed, we had cases of planned VV-ECMO changed to veno-arterial ECMO secondary to TEE findings. Conclusions: Similar to other growing areas of structural and interventional cardiovascular care, DL VV-ECMO placement is a procedure which benefits from live interaction between cardiac imagers and other specialists. In addition to portability, TEE offers confirmation of cardiac function before VV-ECMO insertion, visualization of cannula flow, and immediate identification of procedural related complications which may not be recognized on fluoroscopy. With knowledge of appropriate insertion technique and device function, cardiologists can play an important role in the evaluation for and placement of DL VV-ECMO catheters using TEE.