Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation
© Hirose et al; licensee BioMed Central Ltd. 2012
Received: 19 October 2011
Accepted: 20 April 2012
Published: 20 April 2012
Placement of the Avalon Elite bicaval dual lumen cannula for venovenous extracorporeal membrane oxygenation (VV-ECMO) via the internal jugular vein requires precise positioning of the cannula tip in the inferior vena cava with echocardiography or fluoroscopy guidance. Correct guidewire placement is clearly the key first step in assuring proper advancement of the cannula. We report a case of unexpected wire migration into the right ventricle at the time of final cannula advancement, resulting in right ventricular rupture and tamponade. Transesophageal echocardiography is an important monitoring modality for appropriate placement of the VV-ECMO guidewire and Avalon cannula, and in particular, for early identification of potential complications.
KeywordsECMO Tamponade Surgery Pneumonia Respiratory failure
Correct positioning of Avalon cannula during placement of VV-ECMO is crucial for avoiding complications and to ensure effective oxygenation. The drainage ports of the Avalon cannula should be in the SVC and IVC optimizing removal of deoxygenated blood, with the infusion port in the mid right atrium directed toward the tricuspid valve optimizing delivery of oxygenated blood directly toward the right ventricle and diseased lung. TEE can be an effective modality in confirming proper positioning of cannula. Once the cannula is placed in the correct position, VV-ECMO using Avalon cannula from the right internal jugular access has significant advantage over conventional femoral-femoral or femoral-jugular VV-ECMO. Since Avalon cannula does not require second femoral drainage cannula, the patient is able to sit up, to receive pulmonary toilet and to participate in limited physical therapy, all of which are important in critically ill patients with ARDS.
However, placement of the Avalon cannula may be difficult and has the potential to lead into life threatening complications as described in this report. The guide-wire may not easily advance into the IVC and could migrate across the tricuspid valve and into the right ventricle. This may be caused by the presence of a large Eustachian valve in the right atrium, prohibiting the guidewire passing into the IVC. The wire may curl at the Eustachian valve or in the right atrium and prolapse into the right ventricle. Guidewire malposition should be suspected if there are runs of the premature ventricular complex noted, which should prompt the surgeon to withdraw the guidewire. If the guidewire subsequently migrates to the right ventricle undetected, it could lead to right ventricular rupture from the guidewire, the dilators, or the cannula itself. Avalon cannula placement requires either echocardiographic or fluoroscopic guidance. We use bedside TEE for Avalon cannula placement because most patients requiring VV-ECMO are not stable for transportation to a catheterization or interventional radiology laboratory. Fluoroscopic guidance may however provide better confirmation and continued surveillance of proper guidewire and cannula positioning.
In our patient, we suspect that during the dilator exchanges, the guidewire may have been accidentally pulled back from its originally confirmed position in the IVC and/or prolapsed into the right ventricle just as the final Avalon cannula was being advanced, which occurred simultaneously with loss of visualization of the guidewire within the IVC. The complication was quickly recognized as a new pericardial effusion was appreciated, at the same time as attempting to revisualize the guidewire and cannula position. Subsequently cardiac tamponade was recognized before patient lost her blood pressure, and emergent preparation for pericardial window was performed at the bedside without delay, saving the patient's life.
TEE is an important bedside imaging modality to guide proper placement of the Avalon cannula for VV-ECMO via the internal jugular vein, and can be essential in the early detection of related complications.
Written consent was obtained from the patient for publication of the case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief.
Adult respiratory distress syndrome
Extracorporeal membrane oxygenation
Inferior vena cava
Superior vena cava
Venovenous extracorporeal membrane oxygenation.
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