Preemptive venovenous extracorporeal membrane oxygenation cannulation for post operative pulmonary support in aortic surgery

P0263 

Abstract Submission 

Asad Usman (1), Joyce Ho (1), Jamie Bloom (1), Vincent Sakks (1), Kendall Lawrence (1), Chase Brown (1), Audrey Spelde (1), Jacob Gutsche (1), Wilson Szeto (1), Joseph Bavaria (1)

(1) Hospital of the University of Pennsylvania, Philadelphia, PA

Asad Usman    -  Contact Me
Hospital of the University of Pennsylvania

Joyce Ho    -  Contact Me
Hospital of the University of Pennsylvania

Jamie Bloom    -  Contact Me
Hospital of the University of Pennsylvania

Vincent Sakks    -  Contact Me
Hospital of the University of Pennsylvania

Kendall Lawrence    -  Contact Me
Hospital of the University of Pennsylvania

Chase Brown    -  Contact Me
Hospital of the University of Pennsylvania

Audrey Spelde    -  Contact Me
Hospital of the University of Pennsylvania

Jacob Gutsche    -  Contact Me
Hospital of the University of Pennsylvania

*Wilson Szeto    -  Contact Me
Hospital of the University of Pennsylvania

*Joseph Bavaria    -  Contact Me
Hospital of the University of Pennsylvania

Asad Usman    -  Contact Me
N/A

Introduction

Preexisting comorbid severe lung disease present a unique challenge for patients who require elective or semi-elective aortic surgery. Intraoperative and post operative medical management can include methylpredinsone, inhaled pulmonary vasodilators, beta-2 agonists. In select cases mechanical circulatory support options, such as immediate venovenous extracorporeal membrane oxygenation (VV ECMO) can act as a bridge from cardiopulmonary bypass (CPB). Minimally invasive cardiac surgery, with peripheral drainage cannulation can be used initially for CPB and then for extracorporeal membrane oxygenation as a bridge to rapid recovery. Here we describe 3 cases of elective peripheral cannulation for CPB converted to VV ECMO in patients requiring aortic surgery with concomitant severe lung disease.

Methods

All patients had preoperative pulmonary function testing and CT chest imaging. Cannulation was performed using a 25 French Medtronic (Minneapolis, MN) femoral venous multiorifice drainage cannula and a 21 French Medtronic internal jugular drainage cannula. These two cannulas were Y-bifurcated together as inflow to CPB. At the conclusion of the case after weaning CPB and full reversal of heparin, the aortic cannula was removed and the y-connector in the venous was removed. The femoral cannula was then withdrawn into the IVC/RA junction. A Spectrum medical (Glouster, UK) CP22 pump head and Spectrum Medical Dual Chamber oxygenator were connected to establish VV ECMO. Anti-coagulation was not used for the duration of VV ECMO. VV ECMO flow was maintained at > 4.5 liters per minute and sweep and FiO2 gas flow as titrated as clinically indicated.

Results

Three patients had preoperative planning which included consent for for full VV ECMO support at the conclusion of CPB. The indication for AVR was endocarditis for case 1 and severe aortic regurgitation for case 2 and 3. All three patients had severely reduced lung function. The first case had severe COVID ARDS and was intubated semi-electively prior to the day of surgery. The patient had a restrictive pattern on PFT, with severely reduced FEV1 and severely reduced DLCO on PFTs. The second case had an FEV1 of 31.8% predicted. CT imaging revealed centrilobar lung destruction. The last patient had a predicted FEV1 of 62% with a 42 year smoking history and severe COPD. All 3 patients were successfully extubated from mechanical ventilation and VV ECMO was weaned on day 4, day 1, and day 1 respectively. No ECMO complications were noted. No post operative bleeding was encountered.

Conclusion

VV ECMO can be used as a bridging tool for patients with severe lung disease with high post operative STS risk for pulmonary complications and high risk for prolonged mechanical ventilator. With the advent of MIS aortic surgery, in situ cannulas can be used as a platform for conversion to VV ECMO post CPB. Preoperative planning is necessary to accomplish this transition. With high flow, low shear stress, anticoagulation free VV ECMO is possible, thus mitigating the risk for bleeding post operatively. If RA and or RCP isolation is needed then the cannulas will need to be positioned for correct caval snaring.

Anesthesia and Perioperative Management