Unusual Complication of a Right Ventricular Support–Extracorporeal Membrane Oxygenation Cannula | Cardiology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Unusual Complication of a Right Ventricular Support–Extracorporeal Membrane Oxygenation Cannula

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

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 ECMO13 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.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

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 (abharat@nm.org).

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.

References
1.
Fan  E , Gattinoni  L , Combes  A ,  et al.  Venovenous extracorporeal membrane oxygenation for acute respiratory failure: a clinical review from an international group of experts.   Intensive Care Med. 2016;42(5):712-724. doi:10.1007/s00134-016-4314-7PubMedGoogle ScholarCrossref
2.
Toyoda  Y , Bhama  JK , Shigemura  N ,  et al.  Efficacy of extracorporeal membrane oxygenation as a bridge to lung transplantation.   J Thorac Cardiovasc Surg. 2013;145(4):1065-1071. doi:10.1016/j.jtcvs.2012.12.067PubMedGoogle ScholarCrossref
3.
Bermudez  CA , Rocha  RV , Zaldonis  D ,  et al.  Extracorporeal membrane oxygenation as a bridge to lung transplant: midterm outcomes.   Ann Thorac Surg. 2011;92(4):1226-1231. doi:10.1016/j.athoracsur.2011.04.122PubMedGoogle ScholarCrossref
4.
Rupprecht  L , Lunz  D , Philipp  A , Lubnow  M , Schmid  C .  Pitfalls in percutaneous ECMO cannulation.   Heart Lung Vessel. 2015;7(4):320-326.PubMedGoogle Scholar
5.
Reis Miranda  D , Dabiri Abkenari  L , Nieman  K , Dijkshoorn  M , Duckers  E , Gommers  D .  Myocardial infarction due to malposition of ECMO cannula.   Intensive Care Med. 2012;38(7):1233-1234. doi:10.1007/s00134-012-2583-3PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close