Conclusion
Given the increase in the number of heart transplants off of VA-ECMO,
there is a need for strategies that allow for patient optimization
without further deconditioning. In fact, a protocolized approach by
Coutance and colleagues resulted in equivalent outcomes between patients
undergoing transplant with and without pre-transplant
ECMO5.
Not surprisingly, patients that had not finished transplant listing
prior to ECMO support had a longer duration of ECMO prior to
transplantation (chronic heart failure listed patients (5-8 days) versus
new onset heart failure (12 days)). This suggests a longer period for
optimization in new onset heart failure patients who are new to a system
and have not finished up transplant candidacy decision or have acute end
organ dysfunction that needs to be temporized. We present a novel
approach to ambulatory VA-ECMO with extra-pericardial aortic, via upper
mini sternotomy, and venous cannulation in the internal jugular vein.
Our patient had a BMI of 20 kg/m2 with small stature
and an axillary artery that was 5 mm in size. Vascular complications
following ECMO is the most common cause of death with axillary
cannulation strategy resulting in limb hyperemia in 15% of cases6 and femoral cannulation in up to 20% cases. Anterior thoracotomy with
aortic and right atrial cannulation is a viable strategy but can result
in bleeding into pericardium leading to tamponade physiology. We present
a novel strategy for VA-ECMO cannulation with central aortic cannulation
above the pericardial reflection to avoid violating the pericardium.
This mitigates the risk of bleeding into the pericardium and causing
tamponade, especially on anticoagulation. Secondly, venous drainage in
the right IJ allows greater mobility by leaving both groins free of
cannulas. These advantages make this a viable approach for patients who
require VA ECMO.