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\begin{document}

\title{Utility of three-dimensional transesophageal echocardiography to guide
transseptal positioning of a single multistage venous cannula to provide
both venous drainage and indirect left ventricular venting in
veno-arterial extracorporeal membrane oxygenation.}



\author[1]{Dylan Addis}%
\author[1]{Bo Wang}%
\author[2]{Shane Prejean}%
\author[2]{T. Watts}%
\author[3]{Navin C. Nanda}%
\author[2]{Mustafa Ahmed}%
\affil[1]{UAB}%
\affil[2]{University of Alabama at Birmingham}%
\affil[3]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 16, 2024}


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\selectlanguage{english}
\begin{abstract}
A patient with heart failure due to dilated ischemic cardiomyopathy
presented in cardiogenic shock for institution of veno-arterial
extracorporeal membrane oxygenation as a bridge to cardiac
transplantation. To provide adequate venous drainage and simultaneous
decompression of the left atrium (indirect left ventricular venting) a
single venous cannula was placed across the interatrial septum so the
distal orifice and side ports were located within the left atrium and
the proximal set of side ports at the cavoatrial junction.
Three-dimensional transesophageal echocardiography demonstrated utility
in guiding cannula placement and appropriate positioning within the left
atrium.%
\end{abstract}%



\sloppy


\textbf{KEYWORDS}

Three-dimensional echocardiography, ECMO, transseptal, cannulation,
venting, decompression, three-dimensional transesophageal
echocardiography



\textbf{INTRODUCTION}

A 53 year-old male with chronic combined heart failure (HF) due to
dilated ischemic cardiomyopathy presented in cardiogenic shock to the
hybrid catheterization lab for institution of veno-arterial
extracorporeal membrane oxygenation (VA-ECMO) as a bridge to cardiac
transplantation. To provide adequate drainage and decompression of both
right and left atria the decision was made to place a single venous
cannula across the interatrial septum (IAS) with the goal of positioning
the distal orifice and side ports within the left atrium (LA) and the
proximal set of side ports within the right atrium (RA) or inferior vena
cava (IVC) for left atrial veno-arterial
(LAVA)-ECMO\textsuperscript{1,2}. Three-dimensional (3D) transesophageal
echocardiography (TEE) was employed to guide cannula placement and
positioning.

\textbf{CASE REPORT}

Arterial and venous femoral sheaths were placed, general anesthesia was
induced, the patient intubated, and a transesophageal echocardiography
(TEE) probe placed (\textbf{Movie 1)} . TEE revealed biventricular
dysfunction with a severely dilated left ventricle (LV) (12.1 cm at
end-diastole) (\textbf{Figure 1)} , a LV ejection fraction of
\textless{}10\%, spontaneous echo contrast in all chambers but no
thrombus appreciated, severe mitral and tricuspid regurgitation, a
mitral annuloplasty ring, mild central aortic insufficiency (AI), and a
dilated pulmonary valve annulus (3.8cm) with mild insufficiency. A 6F,
24cm sheath was placed in the superficial femoral artery for antegrade
perfusion of the extremity. Under direct, continuous TEE guidance a BRK
needle (St. Jude Medical, Minnesota, USA) was employed for transseptal
puncture (\textbf{Movie 2} ) and a ProTrack Pigtail Wire (Baylis
Medical, Texas, USA) was inserted. Atrial septostomy was performed with
a 6mm x 40mm peripheral balloon (\textbf{Movie} \textbf{3} ) and the
venous tract was dilated to accommodate the venous cannula. A 23F
Medtronic Bio-Medicus NextGen Multistage Venous Cannula (Medtronic,
Minnesota, USA) was placed and guided in real-time across the IAS using
a combination of live 2D and 3D TEE imaging (\textbf{Movies 4 and 6} ).
Positioning of the venous cannula was achieved using 3D imaging to
optimize distance across the IAS, ensure location of distal orifice and
side ports in relation to the IAS, and avoid damage or interaction with
intracardiac structures (\textbf{Figures 2-4)} (\textbf{Movies 6 and 7}
). Specifically, 3D imaging was integral to visualizing the relationship
of the distal tip of the cannula and side ports to the aorta, the IAS,
and the mitral valve. An orientation of the image to project a view from
the perspective of the base of the heart was particularly useful
(\textbf{Figure 4, Movie 7} ). Measurements were obtained ``online'' at
the time of positioning utilizing 3D multiplanar reconstruction (3DQ
QLAB, Philips Medical Systems, Best, Netherlands) with offline
demonstration of workflow used to align three planes for cannula
measurement presented in \textbf{Figure 5} (4D CARDIOVIEW (v 2.30),
TOMTEC Corporation USA, Illinois, USA).

LAVA-ECMO was initiated and flows adjusted to balance chamber
decompression and to allow for continued opening of the aortic valve
with each cardiac cycle. Color Doppler inflow was noted through the
distal tip and side ports of the cannula within the LA (\textbf{Figure
6} ). The patient was extubated uneventfully and returned to the
cardiothoracic intensive care unit. The patient demonstrated symptomatic
improvement and was able to ambulate in the hallways of the unit with
assistance. Two days after initiation of VA-ECMO the patient underwent
orthotopic heart transplantation. He is currently doing well.

\textbf{DISCUSSION}

VA-ECMO can serve as a bridge to cardiac transplantation in patients
with cardiogenic shock. In peripheral VA-ECMO the arterial cannula
provides retrograde flow toward the aortic valve which increases the
afterload. Blood continues to fill the LV through normal myocardial
blood drainage (Thebesian veins), any systemic venous return that flows
past the ECMO cannula without being entrained, and in some patients
through AI\textsuperscript{3}. When this LV volume cannot be fully
ejected against the increased afterload it leads to progressive LV
distention, increased wall stress, and ultimately myocardial oxygen
utilization. In patients with an incompetent mitral valve (as in our
case), this pressure is transmitted into the LA leading to increases in
LA pressure and potentially precipitating the development or worsening
of cardiogenic pulmonary edema. LV distention in patients on VA-ECMO is
associated with impaired myocardial recovery\textsuperscript{4} and LV
decompression appears to decrease mortality and improve the likelihood
of successful eventual weaning\textsuperscript{5,6}. For these reasons,
multiple LV venting strategies have been developed, though there are no
guidelines regarding patient selection for and timing of LV venting in
VA ECMO. In our patient this decision was driven by the presence of
several factors recognized as indications for LV venting including;
severe, persistent LV dysfunction, markedly dilated left ventricular
chamber with elevated pressures refractory to optimal medical therapy,
and a concern that the observed AI severity could substantially worsen
with the increased afterload of peripheral VA-ECMO\textsuperscript{7}.
Recently, bi-atrial drainage through a single venous cannula for
LAVA-ECMO has been described\textsuperscript{1,2}. The decision to place
a single venous cannula for LAVA-ECMO was based upon a desire to avoid
placement of an additional femoral cannula that would have further
interfered with patient ambulation, and avoidance of the need to
incorporate an additional drainage cannula into the ECMO circuit with
the need for additional tubing, a flow probe, and a flow-regulating
clamp. We describe the first report of 3D TEE to guide placement of a
single LAVA-ECMO venous cannula. In our case, 3D TEE including live 3D
imaging along with ``online'' measurements obtained at the time of
positioning utilizing 3D multiplanar reconstruction were particularly
useful. Furthermore, offline demonstration of workflow used to align
three planes for cannula measurement are presented.

\textbf{CONCLUSION}

3D TEE demonstrates utility in the placement and positioning of a single
femoral venous cannula across the IAS to provide drainage of both left
and right atria for initiation of LAVA-ECMO. This approach is feasible
in appropriate patients and may provide both adequate venous drainage as
well as indirect left ventricular venting. 3D TEE adds increased
confidence in the positioning of the distal and proximal ports required
for bi-atrial drainage.

\textbf{REFERENCES}

1. Whiteside HL, Hillerson D, Coots RD, et al. Safety and Efficacy of
Left Atrial Veno-Arterial (LAVA) Extracorporeal Membrane Oxygenation for
the Management of Cardiogenic Shock. Poster presented at: The Society
for Cardiovascular Angiography and Interventions (SCAI) 2020 Scientific
Sessions; March 14-16, 2020; Virtual Conference

2. Dulnuan K, Guglin M, Zwischenberger J, et al. Left atrial
veno-arterial extracorporeal membrane oxygenation: percutaneous
bi-atrial drainage to avoid pulmonary edema in patients with left
ventricular systolic dysfunction. \emph{Journal of the American College
of Cardiology.} 2018;71(11 Supplement):A1358.

3. Cevasco M, Takayama H, Ando M, et al\emph{.} Left ventricular
distension and venting strategies for patients on venoarterial
extracorporeal membrane oxygenation. \emph{J Thorac
Dis.}2019;11(4):1676-1683.

4. Truby LK, Takeda K, Mauro C, et al. Incidence and Implications of
Left Ventricular Distention During Venoarterial Extracorporeal Membrane
Oxygenation Support. \emph{ASAIO J.} 2017;63(3):257-265.

5. Al-Fares AA, Randhawa VK, Englesakis M, et al. Optimal Strategy and
Timing of Left Ventricular Venting During Veno-Arterial Extracorporeal
Life Support for Adults in Cardiogenic Shock: A Systematic Review and
Meta-Analysis. \emph{Circ Heart Fail.} 2019;12(11):e006486.

6. Kowalewski M, Malvindi PG, Zielinski K, et al. Left Ventricle
Unloading with Veno-Arterial Extracorporeal Membrane Oxygenation for
Cardiogenic Shock. Systematic Review and Meta-Analysis. \emph{J Clin
Med.} 2020;9(4).

7. Xie A, Forrest P, Loforte A. Left ventricular decompression in
veno-arterial extracorporeal membrane oxygenation. \emph{Ann
Cardiothorac Surg.} 2019;8(1):9-18.

\textbf{FIGURE LEGENDS}

\textbf{Figure 1.} Modified mid-esophageal 4-chamber two-dimensional TEE
view obtained prior to cannulation demonstrating severe left ventricular
dilation and increased sphericity. LV: left ventricle, MV: mitral valve,
RV: right ventricle; TEE: transesophageal echocardiography

\textbf{Figure 2.} Live three-dimensional (3D) TEE image obtained during
positioning of the venous cannula across the interatrial septum (IAS)
used for guidance and as the source image to perform multiplanar
reconstruction to measure the distance the cannula tip extended across
the IAS. AV: aortic valve; TEE: transesophageal echocardiography; TV:
tricuspid valve.

\textbf{Figure 3.} Live 3D TEE image of the final cannula tip position
within the left atrium (LA). The green line displays the measured
distance of the cannula across the IAS (43mm) projected onto
three-dimensional space. This measurement was obtained using multiplanar
reconstruction for optimal plane alignment just as performed on the
ultrasound system in the catheterization lab at the time of cannulation
(see Figure 5). .Other abbreviations as in previous figures.

\textbf{Figure 4.} Live 3D TEE image projected to demonstrate a basal
view of the heart aligned in anatomical position to demonstrate the
course of the venous cannula across the IAS. Abbreviations as in
previous figures.

\textbf{Figure 5.} Multiplanar reconstruction of a 3-D dataset (Figure 2
demonstrates original 3-D capture) demonstrating plane alignment on the
venous cannula used to accurately measure the distance the cannula tip
projected into the LA. Abbreviations as in previous figures.

\textbf{Figure 6.} Nonstandard TEE window demonstrating final position
of a 23F Multistage Venous Cannula with color Doppler flow noted at the
distal tip and side ports after initiation of left atrial veno-arterial
(LAVA)-ECMO. Abbreviations as in previous figures.

\textbf{SUPPLEMENTAL INFORMATION}

\textbf{Movies 1-7}

\textbf{MOVIE LEGENDS}

\textbf{Movie 1.} Modified mid-esophageal 4-chamber two-dimensional TEE
view obtained prior to cannulation demonstrating severe left ventricular
(LV) dilation, increased LV sphericity, and severe LV dysfunction.
Spontaneous echo contrast consistent with low flow state is visualized
within the LV. MV: mitral valve, RV: right ventricle; TEE:
transesophageal echocardiography.

\textbf{Movie 2.} Modified aortic valve short-axis image with the TEE
probe retracted slightly and rotated clockwise to center the desired
transseptal puncture site in the two-dimensional image. A BRK
transseptal puncture needle (St. Jude Medical, Minnesota, USA) is
visualized at the center of the image tenting the interatrial septum
(IAS). This image is essential to ensure appropriate orientation of the
transseptal puncture needle in the anterior and posterior planes. Device
leads are seen within the right atrium. TEE: transesophageal
echocardiography

\textbf{Movie 3.} Nonstandard two-dimensional TEE window displaying a
6mm x 40mm peripheral balloon in long axis during atrial septostomy.
After transseptal puncture and wire placement in the left atrium (LA),
the location of the transseptal puncture site should be confirmed and
the balloon position should be visualized in long axis to allow the
imager and proceduralist to confirm location and vector prior to balloon
septostomy. TEE: transesophageal echocardiography

\textbf{Movie 4.} Nonstandard two-dimensional TEE window demonstrating
the advancement of a 23F Medtronic Bio-Medicus NextGen Multistage Venous
Cannula (Medtronic, Minnesota, USA) under direct TEE visualization in
long-axis. IAS: interatrial septum; TEE: transesophageal
echocardiography

\textbf{Movie 5.} Nonstandard two-dimensional TEE window demonstrating
positioning of a 23F Medtronic Bio-Medicus NextGen Multistage Venous
Cannula (Medtronic, Minnesota, USA) under direct TEE visualization in
long-axis after guidewire removal. IAS: interatrial septum; TEE:
transesophageal echocardiography

\textbf{Movie 6.} Live three-dimensional (3D) TEE image used to guide
and adjust position of the venous cannula and side ports within the left
atrium. After satisfactory positioning of the distal and side ports in
relation to intracardiac structures and the interatrial septum (IAS)
this 3-D dataset was obtained and employed for intraprocedural
multiplanar reconstruction to accurately measure the distance across the
IAS. MV: mitral valve; TEE: transesophageal echocardiography.

\textbf{Movie 7.} Live 3D TEE dataset oriented to display a view of the
heart from a basal to apical projection oriented anatomically to
demonstrate final cannula position. 3-D: three-dimensional; AV: aortic
valve; MV: mitral valve; TEE: transesophageal echocardiography; TV:
tricuspid valve.\selectlanguage{english}
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