Percutaneous Dembitsky Bridge Utilizing a Dual-Lumen Cannula

Central MessageThe Protek Duo cannula (LivaNova, PLC) can be implemented with an additional arterial cannula to provide peripheral VAV ECMO. Conversion to RVAD-only support can be performed at the bedside by removing the arterial cannula. The Protek Duo cannula (LivaNova, PLC) can be implemented with an additional arterial cannula to provide peripheral VAV ECMO. Conversion to RVAD-only support can be performed at the bedside by removing the arterial cannula. The Dembitsky bridge is a cannulation strategy that was originally utilized to assess right heart function intraoperatively following left ventricular assist device placement. Utilizing a Y-connected arterial cannula in the pulmonary artery and aorta, with standard venous cannulation, the outflow could be selectively clamped to alternate between cardiopulmonary bypass and right ventricular assist device support.1Dembitsky W.P. Joyce D.L. Chapter 14: right heart dysfunction.in: Joyce D.L. Joyce L.D. Loebe M. Mechanical Circulatory Support: Principles and Clinical Applications. 1st ed. McGraw Hill Medical, 2011: 79-89Google Scholar The work by Dembitsky has found application beyond open cardiopulmonary bypass and into modern extracorporeal membrane oxygenation (ECMO) cannulation strategies. There is increasing interest in peripheral cannulation strategies that can address complex cardiac pathologies without median sternotomy.2Biscotti M. Lee A. Basner R.C. Agerstrand C. Abrams D. Brodie D. et al.Hybrid configurations via percutaneous access for extracorporeal membrane oxygenation: a single-center experience.ASAIO J. 2014; 60: 635-642Crossref PubMed Scopus (68) Google Scholar,3Shah A. Dave S. Goerlich C.E. Kaczorowski D.J. Hybrid and parallel extracorporeal membrane oxygenation circuits.J Thorac Cardiovasc Surg Tech. 2021; 8: 77-85Scopus (15) Google Scholar We present a case of a patient who required emergency conversion from venopulmonary artery (VPa) ECMO to venoarterial (VA) ECMO and developed Harlequin syndrome (HS), which was successfully treated using a percutaneous Dembitsky bridge. A 74-year-old man developed aneurysmal degeneration of a chronically dissected distal arch and descending thoracic aorta after a previously repaired type A aortic dissection. The patient underwent open repair via thoracotomy utilizing deep hypothermic circulatory arrest. Shortly after the initiation of cardiopulmonary bypass, the patient manifested bleeding from the endotracheal tube. This was controlled with isolation of the left lung and was believed to be secondary to a developing aorta-bronchial fistula in the context of aneurysm erosion. The procedure was completed, but persistent difficulties in achieving adequate oxygenation due to right ventricle dysfunction and congestion in the left lung prompted initiation of VA ECMO using the side branch of the aortic graft and a femoral vein cannula. Transesophageal echocardiogram obtained postoperative day 1 revealed persistent right ventricle dysfunction with adequate left ventricle function. The decision was made to transition the patient to VPa ECMO utilizing the Protek Duo (PD) cannula (LivaNova, PLC). After uneventful insertion, the patient was noted to have large-volume hemoptysis with subsequent hemodynamic decompensation. A rapidly expanding left lung hematoma and continued hemodynamic instability necessitated emergent left pneumonectomy. The hematoma appeared to arise internally from the parenchyma of the lung, likely as a secondary complication of the previous bleeding event. Transesophageal echocardiogram demonstrated biventricular dysfunction requiring VA ECMO, which was initiated using the venous outflow portion of the PD and a new percutaneous femoral artery cannula, with the return of the PD clamped (Figure 1). Prior cases had utilized the distal port as an additional inflow cannula, but this typically resulted in cannula thrombosis. This patient began to exhibit signs of differential hypoxia and the return cannula of the PD was Y-connected to the femoral artery inflow cannula (Figure 2). This created a venoarteriovenous (VAV) ECMO configuration—a percutaneous Dembitsky bridge.3Shah A. Dave S. Goerlich C.E. Kaczorowski D.J. Hybrid and parallel extracorporeal membrane oxygenation circuits.J Thorac Cardiovasc Surg Tech. 2021; 8: 77-85Scopus (15) Google ScholarFigure 2Development of Harlequin syndrome-required circuit reconfiguration: The outflow port of the Protek Duo cannula (LivaNova, PLC) was Y-connected to the femoral artery cannula creating a percutaneous Dembitsky bridge.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient was transitioned to VPa-only support on postoperative day 6. He was fully weaned and decannulated on postoperative day 33. Anticoagulation was via heparin infusion, which was briefly held during initial periods of hemorrhage and hemodynamic instability. He was discharged to a rehabilitation facility on postoperative day 51. Institutional review board approval was not required and informed consent waived. HS is a well-described phenomenon in patients requiring VA ECMO. In these patients, increasing cardiac output leads to malperfusion of the arch vessels that can have devastating consequences if not promptly addressed.4Ius F. Sommer W. Tudorache I. Avsar M. Siemeni T. Salman J. et al.Veno-veno-arterial extracorporeal membrane oxygenation for respiratory failure with severe haemodynamic impairment: technique and early outcomes.Interact Cardiovasc Thorac Surg. 2015; 20: 761-767Crossref PubMed Scopus (61) Google Scholar Traditional solutions often required a triple-cannula configuration, including a venous outflow cannula in the femoral vein, with 2 inflow cannulas Y-connected into the femoral artery and internal jugular vein.4Ius F. Sommer W. Tudorache I. Avsar M. Siemeni T. Salman J. et al.Veno-veno-arterial extracorporeal membrane oxygenation for respiratory failure with severe haemodynamic impairment: technique and early outcomes.Interact Cardiovasc Thorac Surg. 2015; 20: 761-767Crossref PubMed Scopus (61) Google Scholar,5Carlson S.F. Smith N.J. Joyce L.D. Joyce D.L. Rossi P.J. Acquired tracheomalacia due to aortic aneurysm managed with venopulmonary extracorporeal membrane oxygenation for perioperative support.J Vasc Surg Cases Innov Tech. 2021; 7: 737-740https://doi.org/10.1016/j.jvscit.2021.09.004Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Normal LV function is imperative to this configuration, and signs of distension should prompt discussion of LV vent placement. Our case report is an example of unexpected derangements in a patient on mechanical circulatory support that required emergency intervention. While receiving VPa ECMO with the PD cannula, the hemodynamic instability and pulmonary hemorrhage resulted in biventricular dysfunction, necessitating VA ECMO. Rapid identification of subsequent HS prompted an additional emergency intervention, which was accomplished by providing oxygenated blood into the pulmonary artery using the previously clamped inflow portion of the PD cannula (Figure 2). The percutaneous Dembitsky bridge utilizing the PD cannula is a complex configuration that may benefit select patients. With a peripheral approach, one can potentially avoid the need for median sternotomy. The sites of insertion allow for 2 surgeons to work concomitantly, enabling rapid implementation in an actively decompensating patient. Lastly, patients who have LV recovery can be converted from VAV ECMO to VPa ECMO with the removal of a single cannula. Although not used routinely, VAV ECMO utilizing the PD cannula is a reliable and rapidly deployable option for patients who require VA ECMO but have sufficient cardiac output to result in HS.