CASE REPORT
Arterial and venous femoral sheaths were placed, general anesthesia was
induced, the patient intubated, and a transesophageal echocardiography
(TEE) probe placed (Movie 1) . TEE revealed biventricular
dysfunction with a severely dilated left ventricle (LV) (12.1 cm at
end-diastole) (Figure 1) , a LV ejection fraction of
<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 (Movie 2 ) and a ProTrack Pigtail Wire (Baylis Medical,
Texas, USA) was inserted. Atrial septostomy was performed with a 6mm x
40mm peripheral balloon (Movie 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 (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 (Figures 2-4) (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 (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 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 (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.