Oxygenated right ventricular assist device as part of veno-venopulmonary extracorporeal membrane oxygenation to support the right ventricle and pulmonary vasculature

Right Ventricular Assist Device With an Oxygenator for the Management of Combined Right Ventricular and Respiratory Failure: A Systematic Review

BACKGROUND

Severe lung disease frequently presents with both refractory hypoxemia and right ventricular (RV) failure. Right ventricular assist device with an oxygenator (OxyRVAD) is an extracorporeal membrane oxygenation (ECMO) configuration of RV bypass that also supplements gas exchange. This systematic review summarises the available literature regarding the use of OxyRVAD in the setting of severe lung disease with associated RV failure.

METHODS

PubMed, Embase, and Google Scholar were queried on September 27, 2023, for articles describing the use of an OxyRVAD configuration. The main outcome of interest was survival to intensive care unit (ICU) discharge. Data on the duration of OxyRVAD support and device-related complications were also recorded.

RESULTS

Out of 475 identified articles, 33 were retained for analysis. Twenty-one articles were case reports, and 12 were case series, representing a total of 103 patients. No article provided a comparison group. Most patients (76.4%) were moved to OxyRVAD from another type of mechanical support. OxyRVAD was used as a bridge to transplant or curative surgery in 37.4% and as a bridge to recovery or decision in 62.6%. Thirty-one patients (30.1%) were managed with the dedicated single-access dual-lumen ProtekDuo cannula. Median time on OxyRVAD was 12 days (interquartile range 8-23 days), and survival to ICU discharge was 63.9%. Device-related complications were infrequently reported.

CONCLUSION

OxyRVAD support is a promising alternative for RV support when gas exchange is compromised, with good ICU survival in selected cases. Comparative analyses in patients with RV failure with and without severe lung disease are needed.

Assessing Right Ventricle Over Time in Patients on Veno-Venous Extracorporeal Membrane Oxygenation: Insights From Serial Echocardiography

Extracorporeal membrane oxygenation (ECMO) is often used in acute respiratory distress syndrome (ARDS) with refractory hypoxemia. There is limited literature highlighting the development of right ventricular (RV) failure while on ECMO. We conducted a retrospective multicenter observational study including 70 patients who were placed on veno-venous (VV)-ECMO for respiratory failure at Mayo Clinic, Jacksonville, and Mayo Clinic, Rochester, between January 2018 and June 2022 and had at least two post-ECMO transthoracic echoes. The primary outcomes were the incidence and progression of RV dysfunction and dilatation. The secondary outcome was in-patient mortality. Among 70 patients in our cohort, 60.6% had a normal RV function at the time of ECMO placement, whereas only 42% had a normal RV function at the second post-ECMO echo. On multinomial regression, a moderate decrease in RV function was associated with ECMO flow (odds ratio [OR] = 2.32, p = 0.001) and ECMO duration (OR = 1.01, p = 0.01). A moderately dilated RV size was also associated with ECMO flow (OR = 2.62, p < 0.001) and ECMO duration (OR = 1.02, p = 0.02). An increasing degree of RV dysfunction was associated with worse outcomes. Our study showed that the increasing duration and flow of VV-ECMO correlated with progressive RV dilatation and dysfunction, which were associated with poor survival.

The intricate physiology of veno-venous extracorporeal membrane oxygenation: an overview for clinicians

During veno-venous extracorporeal membrane oxygenation (V-V ECMO), blood is drained from the central venous circulation to be oxygenated and decarbonated by an artificial lung. It is then reinfused into the right heart and pulmonary circulation where further gas-exchange occurs. Each of these steps is characterized by a peculiar physiology that this manuscript analyses, with the aim of providing bedside tools for clinical care: we begin by describing the factors that affect the efficiency of blood drainage, such as patient and cannulae position, fluid status, cardiac output and ventilatory strategies. We then dig into the complexity of extracorporeal gas-exchange, with particular reference to the effects of extracorporeal blood-flow (ECBF), fraction of delivered oxygen (FdO2) and sweep gas-flow (SGF) on oxygenation and decarbonation. Subsequently, we focus on the reinfusion of arterialized blood into the right heart, highlighting the effects on recirculation and, more importantly, on right ventricular function. The importance and challenges of haemodynamic monitoring during V-V ECMO are also analysed. Finally, we detail the interdependence between extracorporeal circulation, native lung function and mechanical ventilation in providing adequate arterial blood gases while allowing lung rest. In the absence of evidence-based strategies to care for this particular group of patients, clinical practice is underpinned by a sound knowledge of the intricate physiology of V-V ECMO.

ProtekDuo percutaneous ventricular support system-physiology and clinical applications

The ProtekDuo (LivaNova, London, UK) cannula is a dual-lumen device, typically inserted into the right internal jugular (IJ) vein through a percutaneous approach, with fluoroscopy or ultrasound guidance. When connected to a pump, such as the TandemHeart (LivaNova, London, UK) or CentriMag (Abbott, Pleasanton, CA, USA), it can function as a right ventricular (RV) mechanical circulatory support (MCS). When an oxygenator is also added [veno-pulmonary (V-P)], it can provide extracorporeal membrane oxygenation (ECMO) support. This review aims to provide a comprehensive overview of the device's physiology and clinical applications. In the setting of RV failure (RVF), the ProtekDuo cannula, with its outflow in the main pulmonary artery (PA), can bypass the failing RV, improving pulmonary flow, left atrial (LA) filling pressures, and left ventricular (LV) preload. This can also reduce ventricular interdependence and leftward shift of the interventricular septum that occurs in RVF. In this review, the key sections expand on the use of the ProtekDuo cannula in the management of critically ill patients, specifically, the use of ProtekDuo for RV myocardial infarction (MI) RVF, LV assist device (LVAD) implantation-associated RVF, RVF post-heart transplantation, temporary biventricular MCS as bridge to recovery (ECpella 2.0 or PROpella), biventricular support as bridge to recovery or decision, isolated LV failure, post lung transplantation (LT) care, and other miscellaneous clinical scenarios. ProtekDuo is an important tool in the armory of RVF management. The ProtekDuo system is expected to gain more popularity given its clear advantages such as groin-free approach allowing for mobility, easy percutaneous deployment, compatibility with various pumps and oxygenators, and the versatility to be integrated in numerous configurations. In an era of expanding MCS options, further research is needed to better understand the optimal tool for specific patient subsets.