References
1. Burrell AJC, Ihle JF, Pellegrino VA, Sheldrake J, Nixon PT. Cannulation technique: femoro-femoral. J Thorac Dis. 2018; 10: 616–623.
2. Abrams D, Bacchetta M, Brodie D, Recirculation in venovenous extracorporeal membrane oxygenation, ASAIO J. 2015;61:115-21.
3. Messai E, Bouguerra A, Guarracino F, Bonacchi M. Low Blood Arterial Oxygenation During Venovenous Extracorporeal Membrane Oxygenation: Proposal for a Rational Algorithm-Based Management. J Intensive Care Med. 2016; 31: 553-60.
4. Darling EM, Crowell T, Searles BE. Use of dilutional ultrasound monitoring to detect changes in recirculation during venovenous extracorporeal membrane oxygenation in swine. ASAIO J. 2006; 52: 522-4.
5. Palmér O, Palmér K, Hultman J, Broman M. Cannula Design and Recirculation During Venovenous Extracorporeal Membrane Oxygenation. ASAIO J. 2016; 62: 737-742.
6. Bermudez CA, Rocha RV, Sappington PL, Toyoda Y, Murray HN, Boujoukos AJ. Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults. Ann Thorac Surg. 2010; 90: 991-5
7. Rubino A, Vuylsteke A, Jenkins DP, Fowles JA, Hockings L, Valchanov K. Direct complications of the Avalon bicaval dual-lumen cannula in respiratory extracorporeal membrane oxygenation (ECMO): Single-center experience. Int J Artif Organs. 2014;37:741–7.
8. Bonacchi M, Harmelin G, Peris A, Sani G. A novel strategy to improve systemic oxygenation in venovenous extracorporeal membrane oxygenation: the ”χ-configuration”. J Thorac Cardiovasc Surg. 2011; 142: 1197-204.
9. Hori D, Noguchi K, Nomura Y, Tanaka H. Extracorporeal membrane oxygenation with double venous drainage. Ann Thorac Cardiovasc Surg. 2014; 20: 836-8.
Figure 1. Chest AP (1A) and result of ELSA monitor (1B) after applying VV ECMO.
The cannula positioned at superior vena cana and junction of right atrium and inferior vena cava. The recirculation, measured by ELSA monitor, was 28%. (yellow and black dot arrow; return and drainage cannula)
Figure 2. Alternative position of cannulae (2A) and ELSA monitor during changing a position of cannulae (2B).
Overlap distance was 8.75cm between a return (yellow arrow) and a drainage cannula (black dot arrow) Before repositioning procedure, a recirculation rate was 26%. After advancing the drainage until superior vena cava, and return cannula 2cm, a recirculation rate increased 30%. After advancing the return cannula 1cm additionally, a recirculation rate was 24%. The next day, a recirculation rate was 14% after VV-ECMO flow was decreased.
Figure 3. The schematic figure for the alternative position of cannulae.
This alternative position of cannulae in VV-ECMO can drain from superior and inferior vena cava (blue arrow) but develop the recirculation (violet arrow). The optimal position of the return cannula is determined by dilution ultrasound monitoring, which position may make oxygenated blood (red arrow) flow to the right ventricle.