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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