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A previously healthy, middle-aged patient presented with rapidly increasing shortness of breath despite empirical antibiotic treatment for presumed pneumonia. A computed tomographic image of the chest was notable for diffuse, ground-glass opacities. An infectious disease workup was unrevealing, and the patient was diagnosed with acute-on-chronic respiratory failure resulting from dermatomyositis-associated interstitial lung disease. Progressive hypoxia refractory to mechanical ventilation necessitated venovenous extracorporeal membrane oxygenation (VV ECMO) using the ProtekDuo dual-lumen cannula (LivaNova). In its standard configuration, deoxygenated blood is drained from the right atrium while oxygenated blood is ejected into the main pulmonary artery, and the device serves as both a right ventricular support and an ECMO (RVS-ECMO) cannula. End-stage lung disease was established and, as part of a lung transplant evaluation, the patient underwent catheterization of the left side of the heart and coronary angiography. The left coronary artery angiogram revealed mild luminal irregularities. The right coronary artery (RCA) angiogram is shown in Figure 1 and Video 1.
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Right coronary artery compression by the right ventricular angulation of the RVS-ECMO cannula
C. Reposition the cannula and repeat the angiogram
The key to the diagnosis is recognizing the potential of cannulae within the right ventricle to compress the RCA (Figure 2; Video 2). While this may not be clinically significant, as in the present case, it may result in malignant arrhythmias or myocardial infarction. Failure to recognize and correct this phenomenon may lead to unnecessary procedures, such as a coronary intervention. Since patient mobilization prior to lung transplant improves posttransplant outcomes, dual-lumen cannulae, such as ProtekDuo, placed from the right internal jugular vein are increasingly used for VV ECMO1- 3 to promote preoperative and postoperative mobilization of patients receiving lung transplants. The most common complications of VV ECMO include vascular injury, bleeding, and hemolysis,2,4 but myocardial infarction secondary to coronary artery compression has been described.5 This report illustrates how the hinge point of the RVS-ECMO cannula in the right ventricle of the RCA may cause extrinsic compression to the RCA. A U-shaped configuration of the cannula, with a less acute angle, is less likely to cause this than a more acute V-shape configuration. If a V shape is recognized after advancing the distal tip of the cannula to the desired position, we advise retracting the cannula under fluoroscopic guidance, which attenuates the angle at the hinge point of the cannula.
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Corresponding Author: Ankit Bharat, MD, Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 676 N Saint Clair St, Ste 650, Chicago, IL 60611 (email@example.com).
Published Online: March 17, 2021. doi:10.1001/jamacardio.2021.0284
Conflict of Interest Disclosures: Dr Bharat reported being supported by the National Institutes of Health (grants HL145478, HL147290, and HL147575). No other disclosures were reported.
Additional Contributions: The authors are thankful to Elena Susan, MS, Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, for the formatting of the manuscript and its submission to the journal. She was not compensated for this contribution.
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