Discussion
VV- ECMO is indicated in patients with severe respiratory failure that is refractory to optimal mechanical ventilation, medical therapy, patients with reversible respiratory failure including acute respiratory distress syndrome (ARDS)10 and as a bridge to lung transplantation. 3 However, patients with irreversible failure and those who are not eligible to be bridged to lung transplants should not be placed on VV-ECMO cannulation.10 So, an exit strategy should be available before selecting the patient as a VV-EECMO candidate. Currently, there are four dual lumen cannula systems from different companies, including the Protek Duo/RD™ and Avalon Elite™.
Considering the difference between the Protek Duo RD™ and the Avalon cannula, there have been concerns in not using any heparin in the clinical practice.
The Protek Duo RD™ has multiple inflow holes on the most distal portion of the cannula and several outflow holes on the central part of the cannula, which we assume permits for more laminar blood flow as opposed to turbulent flow seen in the Avalon Elite™ cannula, which has a single outflow port. Turbulent blood flow could be the cause of more hemolysis in the Avalon cannula. Laminar flow is more similar to normal physiological conditions and has a lower Reynolds number. The lower Reynolds number is directly proportional to velocity and will result in less shear stress on the vessels. Furthermore, adequate flow is produced; this allows for a high flow which will result in recirculation. Turbulent flow produces low flow which will result in reduced movement and low shear stress; which are major risk factors for thrombosis formation.
We assume that the circumferential holes in the Protek Duo RD™ allow a better laminar flow of the oxygenated blood in the cannula when comparing with the flow pattern in the Avalon cannula which has only one quadrangle outflow.
Furthermore, the positioning of the cannula is considerably easier in the instance of the Protek Duo RD™cannula, as it permits circumferential delivery of oxygenated blood. In the case of the Avalon cannula, if the outflow is presenting away from the tricuspid valve, it requires meticulous repositioning. Hence, the Protek Duo RD™cannula is easier to position without requiring more TEE or TTE guided positioning.
In this patient, the Protek Duo RD™ was conveniently and effectively used. It improved patient rehabilitation while minimizing blood loss and risk of thrombosis, and shortened procedure time while improving clinical outcomes in right ventricular failure. To our surprise, as we did not have any other clinical bailout; our patient tolerated very well being on VV-ECMO for several weeks without IV Heparin. Moreover, even with extensive application of pro-coagulation factors, including Factor 7, the patient did not clot off the ECMO circuit despite a routine oxygenated change during the pre-transplant hospital stay.
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