key: cord-0945509-gbnk5xpj
authors: Kumar, Kris; Coonse, Kendra; Zakhary, Bishoy; Cigarroa, Joaquin E.
title: Novel method for left ventricular unloading utilizing percutaneous pulmonary artery drainage in cardiorespiratory failure due to COVID‐19 infection
date: 2022-04-21
journal: Catheter Cardiovasc Interv
DOI: 10.1002/ccd.30212
sha: e93b50014f1b38c0d012d842fa2286b8cc293830
doc_id: 945509
cord_uid: gbnk5xpj

Left ventricular (LV) unloading is an important concept in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (VA‐ECMO). We present a case of a 32‐year‐old male in acute cardiorespiratory collapse due to coronavirus disease (COVID‐19) who underwent VA‐ECMO cannulation in the setting of cardiogenic shock and acute respiratory distress syndrome. Due to inability to utilize percutaneous LV assist device (pLVAD) for LV unloading due to small end diastolic dimension, alternative strategies were explored. A traditionally utilized right ventricular support device, the ProTek Duo (TandemLife, Pittsburgh, PA), was utilized to drain the pulmonary artery, leading to improvement in parameters for cardiogenic shock. To our knowledge, this is the first case in which a ProTek Duo has been utilized in conjunction with VA‐ECMO to provide LV unloading in support of a patient in cardiogenic shock. This method can be employed in future challenging situations where pLVAD is not feasible.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a form of mechanical circulatory support (MCS) utilized to provide full cardiopulmonary support in patients with cardiorespiratory collapse as a potential bridge to recovery, durable device or transplant. 1 Novel coronavirus disease (COVID-19) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for a global pandemic that has increased the consideration and use of ECMO in patients with isolated pulmonary manifestations of the disease as well as in patients with cardiogenic shock, requiring arterial cannulation. [2] [3] [4] [5] Utilization of VA-ECMO can intrinsically alter the left ventricular (LV) hemodynamics through a consequent increase in afterload secondary to retrograde arterial flow via the arterial cannula. Patients with reduced ventricular contractility will experience increased ventricular pressure, volume, and distention due to an inability to generate sufficient pressure to open the aortic valve against the resistance due to retrograde flow generated by the ECMO circuit. 6 Thus, following unloading, the patient's hemodynamic profile moves downward and to the left on the pressure volume relationship.

Strategies employed to provide LV unloading with the use of VA-ECMO include medical therapy via inotropes and vasodilators, intra-aortic balloon pump, surgical venting, atrial septostomy, and currently the most commonly employed strategy, percutaneous LV assist device (pLVAD) ( Table 1) . However, each venting strategy has its own benefits and limitations with regard to the hemodynamic profile achieved and risks associated with placement and use. We 

A 32-year-old male with a past medical history of obesity presented with a chief complaint of ageusia, nausea, and diarrhea and was found to be COVID-19 positive. The patient was started on high flow nasal cannula in the setting of hypoxemia as well as remdesivir, dexamethasone, and toculizumab. Due to worsening acute respiratory distress syndrome (ARDS), the patient was subsequently intubated and started on mechanical ventilation. Following shock team and ECMO team discussion, the decision was made to proceed Despite conversion to VA-ECMO while on multiple vasoreactive medications, the patient had ongoing shock and persistent systemic hypoperfusion with a rising lactic acid to 28 mmol/L. MAP was elevated to 89 mmHg following VA-ECMO cannulation, and LV dimensions increased to 4.5 cm. Due to lack of pulsatility and need for more flow with evidence of increased LV distention, an urgent need for LV unloading/venting strategy was required. In the setting of a small LV dimensions before ECMO cannulation, it was determined that a pLVAD would not be effective. Thus, the decision was made to proceed with placement of a ProTek Duo device as a collective right atrial and PA drainage device in a reverse configuration to drain the right heart and subsequently unload the LV.

The patient was brought to the cardiac catheterization laboratory urgently and the right internal jugular venous return cannula was cross clamped. An 18-G needle then introduced into the cannula to allow for an 0.035 in. wire to advance into the right ventricle. The cannula was then removed, and an 18-Fr sheath then advanced over a wire into the right internal jugular vein. A 7-Fr balloon wedge catheter was then advanced into the distal right branch PA, with a 0.035 in. extra stiff wire advanced into the catheter to allow for extra support. The catheter was then withdrawn over the wire, and the right internal jugular vein was dilated progressively to a 24-Fr size before advancement of the ProTek Duo into the right PA (Figure 1 ).

The right ventricular support device was then connected to the ECMO circuit and configured to withdraw blood from the PA and return oxygenated blood into the arterial cannula. Previously, PA drainage has been explored in porcine models for VA-ECMO LV unloading with promising results, allowing for maintenance of end-organ function as well as reduction in overall stroke work and pressure/volume area reductions. 8 Direct PA venting has been attempted through cannulas in the PA in both adult and pediatric patients as described in previous case series. [9] [10] [11] The use of ProTek Duo configuration however can allow for flows up to 4.5 L/min to provide maximal LV unloading and reduction in LV distention and risk for pulmonary edema. This was especially true in our patient due to concurrent COVID-19 infection and severe ARDS.

Other strategies for unloading in this patient where pLVAD is not suitable due to LV size include surgical venting as well as direct left atrial septostomy to allow for LV unloading. 12 However, due to acute critical illness surgical venting was not pursued. 

Venoarterial extracorporeal membrane oxygenation in cardiogenic shock

World Health Organization. Coronavirus disease (COVID-19) Pandemic

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Association of coronavirus disease 2019 (COVID-19) with myocardial injury and mortality

Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan China

Venoarterial extracorporeal membrane oxygenation for cardiogenic shock and cardiac arrest

Outcomes with the tandem protek duo dual-lumen percutaneous right ventricular assist device

Transaortic or pulmonary artery drainage for left ventricular unloading in venoarterial extracorporeal life support: a porcine cardiogenic shock model

Percutaneous left-heart decompression during extracorporeal membrane oxygenation: an alternative to surgical and transeptal venting in adult patients

Extracorporeal membranous oxygenation and left atrial decompression: a fast and minimally invasive approach

Modalities and effects of left ventricle unloading on extracorporeal life support: a review of the current literature

Left ventricular unloading during veno-arterial ECMO: a review of percutaneous and surgical unloading interventions

Novel method for left ventricular unloading utilizing percutaneous pulmonary artery drainage in cardiorespiratory failure due to COVID-19 infection

The authors declare no conflicts of interest.

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

https://orcid.org/0000-0003-4797-1165