Comparison of the Avalon Dual-Lumen Cannula with Conventional Cannulation Technique for Venovenous Extracorporeal Membrane Oxygenation.

Comparison of two kinds of cannulation (double-lumen cannula [DLC, Avalon Elite Bicaval Dual Lumen Catheter] and conventional cannulation with two cannulas) for venovenous extracorporeal membrane oxygenation (ECMO) therapy in terms of effectiveness, usage complexity, and costs. Retrospective case series of 17 patients who received venovenous ECMO therapy due to acute respiratory distress syndrome (ARDS) between January 2010 and March 2012. Nine patients were treated with the DLC and eight patients with conventional cannulation. We analyzed the outcome data, ECMO values, respirator settings, blood gas values, realized prone positioning, and costs, and compared both methods. Both kinds of cannulation are efficient regarding oxygenation and decarboxylation. There is no significant difference in mortality, hospitalization time (intensive care unit [ICU] and hospital) and complications during ECMO therapy between both groups. Cannula implantation is much more complex in the DLC group and requires more experience in TEE (transesophageal echocardiography) diagnostics and cannulation technique. In addition, the costs for the Avalon (MAQUET Cardiopulmonary AG, Germany) cannula are significantly higher than for conventional cannulation. Furthermore, prone positioning could be easier achieved in the DLC group. In summary, double-lumen cannulation allows sufficient gas exchange with more effort (material, technical, and physicians' experience) and higher costs but better mobilization possibilities (particularly prone position) and potential avoidance of deep sedation and mechanical ventilation. From the current point of view, the DLC should be reserved for special cases.

Kuhl T ，Michels G ，Pfister R ，Wendt S ，Langebartels G ，Wahlers T ... -  《-》

Bicaval dual-lumen cannula for venovenous extracorporeal membrane oxygenation: Avalon© cannula in childhood disease.

Severe acute refractory respiratory failure is considered a life-threatening situation, with a high mortality of 40 to 60%. When conservative oxygenation methods fail, a lifesaving measure is the introduction of extracorporeal membrane oxygenation (ECMO). Venovenous ECMO (VV-ECMO) is a preferred modality of support for patients with refractory acute respiratory failure. Specifically, bicaval VV-ECMO is a well-recognized and validated therapy, where single or double periphery venous access is used for the insertion of two differently sized cannulas in order to achieve adequate blood oxygenation. Compared to venoarterial ECMO, in VV-ECMO, the rate of complications, such as thrombosis, bleeding, infection and ischemic events, is lower. On the other hand, the size and insertion location is an obstacle to patient mobilization. This is a considerable problem for patients where the time interval for lung recovery and the bridge to the transplantation is prolonged. To address this issue, a dual-lumen, single venovenous cannula was introduced. Here, by insertion of one single catheter in one target vessel, in a majority of cases in the right internal jugular vein, satisfactory oxygenation of the patient is achieved. In this form, the instituted VV-ECMO enables patient mobility, better physical rehabilitation and facilitates pulmonary extubation and toilet. However, relatively early, after the first short-term reports were published, a relatively high complication rate became evident. In the recent literature, the complication rate using actual commercially available double-lumen venovenous cannula ranges between 5 and 30%. These cases were mostly conjoined to the implantation phase or the early postoperative phase and vary between right heart perforation to migration of the cannula. This review focuses on complications allied to commercially available dual-lumen, single, venovenous cannula implantation, pointing out the critical segments of the implantation process and analyzing the structure of the device.

Berdajs D 《-》

Transesophageal Echocardiography Compared to Fluoroscopy for Avalon Bicaval Dual-Lumen Cannula Positioning for Venovenous ECMO.

Hemamalini P ，Dutta P ，Attawar S 《-》

A novel strategy to improve systemic oxygenation in venovenous extracorporeal membrane oxygenation: the "χ-configuration".

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used in refractory acute respiratory distress syndrome where lung recovery is the primary goal. For its achievement, adequate extracorporeal blood flow and a maximal separation between oxygenated (inflow) and deoxygenated (outflow) blood flow are essential for reducing the recirculation phenomenon. We introduce the χ-configuration, a new cannulation strategy for VV-ECMO. We report our experience with 30 VV-ECMO consecutive patients: in 16 patients (group NS) we applied the χ-configuration, which consists of a particular right atrial cannula arrangement and a self-made modified inflow cannula, consisting of an outflow multihole venous cannula that was inserted percutaneously through the right femoral vein, into the right atrium, just below on the superior vena cava, and a self-made modified curved inflow cannula (inserted percutaneously through the right internal jugular vein) that, in its terminal segment, permitted the tip to be positioned close to the tricuspid valve. In 14 patients (group C) we applied the standard femoro-jugular VV-ECMO 2-cannula setting. In both groups, efficacy of blood oxygenation was obtained by gas-blood analysis, by blood samples obtained at arterial, central venous, and pulmonary artery lines, and by ECMO inflow and outflow lines. The recirculation fraction was obtained by a specific bedside formula. No differences were noted between groups regarding the pre-ECMO patient characteristics. No complications during cannulation were recorded. In group NS, on-ECMO time, post-ECMO mechanical ventilation time, and ECMO overall results were significantly better than in group C. During high-flow VV-ECMO, pulmonary and systemic arterial oxygen saturation and arterial oxygen tension were significantly higher in group NS, and blood recirculation fraction was significantly lower. Our data indicate that χ-configuration can be safe, feasible, and more effective than conventional VV-ECMO. It permits near complete drainage of the desaturated blood and a preferential oxygenated blood inflow toward the tricuspid valve, resulting in a significant reduction of recirculation, thereby improving the patient's oxygenation. Our innovative strategy reduces on-ECMO and post-ECMO mechanical ventilation time, gives a faster and better pulmonary recovery, improves survival, and can reduce hospital costs.

Bonacchi M ，Harmelin G ，Peris A ，Sani G ... -  《-》

Initial experience with single-vessel cannulation for venovenous extracorporeal membrane oxygenation in pediatric respiratory failure.

Fallon SC ，Shekerdemian LS ，Olutoye OO ，Cass DL ，Zamora IJ ，Nguyen T ，Kim ES ，Larimer EL ，Lee TC ... -  《Pediatric Critical Care Medicine》