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\begin{document}

\title{Dual-outflow extracorporeal membrane oxygenation support in secondary
right ventricular failure}



\author[1]{Florian Hecker}%
\author[1]{Harald Keller}%
\author[1]{Ina Ischewski}%
\author[1]{Mariuca Vasa-Nicotera}%
\author[1]{Sonja Iken}%
\author[1]{Tomas Holubec}%
\affil[1]{Hospital of the Goethe University Frankfurt}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Acute-on-chronic right ventricular failure has a tremendously high
mortality rate and pulmonary artery hypertension plays a major role in
the progression of secondary right ventricular failure. Here, we report
a case of drug-refractory acute-on-chronic right ventricular failure due
to primary artery hypertension and a two-step approach of a percutaneous
dual-outflow extracorporeal membrane oxygenation support set-up
implanted under on-going mechanical resuscitation for immediate
biventricular support with a consequent downgrade to right ventricular
assist device after left ventricular recompensation.%
\end{abstract}%



\sloppy


\emph{Title page:}

\textbf{Title:} Dual-outflow extracorporeal membrane oxygenation support
in secondary right ventricular failure

\textbf{Running Head:} Percutaneous dual-outflow ECMO with RVAD

\textbf{Authors} \textbf{:} Florian Hecker, MD\textsuperscript{1},
Harald Keller, M.Sc.\textsuperscript{1}, Ina Ischewski,
B.Sc.\textsuperscript{1}, Mariuca Vasa-Nicotera, MD\textsuperscript{2},
Sonja Iken, MD\textsuperscript{3} and Tomas Holubec, MD,
PhD\textsuperscript{1}

\textbf{Institutions an Affiliations:} \textsuperscript{1} Department of
Cardiovascular Surgery, University Hospital Frankfurt and Johann
Wolfgang Goethe University Frankfurt, Frankfurt, Germany

\textsuperscript{2} Department of Internal Medicine III, Cardiology,
University Hospital Frankfurt and Johann Wolfgang Goethe University
Frankfurt, Frankfurt, Germany

\textsuperscript{3} Department of Anesthesiology, Intensive Care
Medicine and Pain Therapy, University Hospital Frankfurt and Johann
Wolfgang Goethe University Frankfurt, Frankfurt, Germany

\textbf{Statements:}

The data that support the findings of this study are available from the
corresponding author upon reasonable request.

Funding: None.

Conflict of Interest: None.

Institutional Review Board approval: not required at our institution.

Patient consent: was obtained.

\textbf{Corresponding Author:}

Assoc. prof. Tomas Holubec, MD, PhD

Department of Cardiovascular Surgery

University Hospital Frankfurt

Theodor-Stern-Kai 7

60596 Frankfurt am Main/Germany

Tel.: +49 69 6301 80094

Email: tomasholubec@email.cz

\emph{Abstract:}

Acute-on-chronic right ventricular failure has a tremendously high
mortality rate and pulmonary artery hypertension plays a major role in
the progression of secondary right ventricular failure. Here, we report
a case of drug-refractory acute-on-chronic right ventricular failure due
to primary artery hypertension and a two-step approach of a percutaneous
dual-outflow extracorporeal membrane oxygenation support set-up
implanted under on-going mechanical resuscitation for immediate
biventricular support with a consequent downgrade to right ventricular
assist device after left ventricular recompensation.

\emph{Text:}

\textbf{Introduction}

Drug-refractory right ventricular failure (RVF) is mostly caused by
pressure and volume overload of the right ventricle (RV) due to its
limited muscular pump function. Pulmonary artery hypertension (PAH) is
an important contributing factor leading to the progression of secondary
RVF (s-RVF).\textsuperscript{1} Especially acute-on-chronic s-RVF has a
tremendously high mortality rate with up to
40\%.\textsuperscript{2}Mechanical circulatory support of the RV may be
the only therapeutic strategy facing this rapidly progressive syndrome
and was reported to be successful with various percutaneous cannulation
techniques in cases of RVF due to myocardial infarction, after left
ventricular assist device implantation and prior lung
transplantation.\textsuperscript{3, 4}

Herewith, we describe our experience with a percutaneously implanted
right ventricular assist device (RVAD) combined with a regular
veno-arterial extracorporeal membrane oxygenation (ECMO) set-up in a
patient with acute s-RVF due to PAH under on-going resuscitation.

This case report does not require Institutional Review Board approval at
our institution and the informed consent was obtained from the patient.

This case report does not require IRB review at our institution and the

patient has given consent for their case to be used for educational

purposes.

\textbf{Case report}

A 65-year-old male patient was admitted to the hospital presenting with
acute coronary syndrome. The coronary angiography showed a
hemodynamically relevant in-stent re-stenosis of the left anterior
descending and ramus intermedius artery. The first intervention was done
23 years ago, followed by multiple re-interventions due to recurrent
in-stent re-stenosis in all three coronary vessels. Echocardiography
revealed preserved left ventricular function with reduced RV function.
The tricuspid annular plane systolic excursion (TAPSE) was at 14~mm
without dilatation of the tricuspid valve anulus (28~mm) but signs of RV
dilatation. The approximated systolic pulmonary artery pressure (PAP)
over the tricuspid valve was measured with 100~mmHg plus central venous
pressure. The patient underwent a right heart catheterization which
confirmed the elevated systolic PAP of 90~mmHg with a regular pulmonary
capillary wedge pressure and, following supplementary CT-angiography,
was diagnosed with a precapillary idiopathic type I PAH. Due to his
coronary state with unstable angina but subclinical PAH, the patient has
been indicated for coronary treatment. Without an option for
interventional therapy, the patient was scheduled for urgent minimally
invasive direct coronary artery bypass surgery.

Despite maximal PAH specific preventive measures during induction of
anesthesia, the patient became hemodynamically unstable requiring
cardiopulmonary resuscitation. Return of spontaneous circulation was
achieved shortly using high doses of inotropic agents. Due to no signs
of new acute ischemic heart abnormalities the surgery was postponed, and
due to circulatory instability despite maximal inotropic support
mechanical circulatory support was indicated. Under on-going mechanical
resuscitation, a veno-arterial-venous, respectively pulmonary artery
(PA) ECMO (V-A-V/PA ECMO) was established \textbf{(Fig.~1)} . An inflow
cannula was inserted percutaneously via the right femoral vein (Getinge
HLS 23F, 55 cm; Rastatt, Germany) into the right atrium and an outflow
cannula was inserted into the right femoral artery (Getinge HLS 17F, 23
cm) for initial stabilization. Thereafter, a soft guidewire was placed
percutaneously via the right internal jugular vein through the
tricuspid- and pulmonary valve, with its tip into the PA common trunk
under fluoroscopic control in the catheterization lab.
(see\textbf{video} demonstration for the percutaneous deployment of the
21F outflow cannula via internal jugular vein to the pulmonary trunk
over an extra-stiff guide wire and the final result after removing the
cannula's inner sheath under fluoroscopic vision) The soft guidewire was
then exchanged via a pigtail catheter for an extra-stiff wire
(Lunderquist\textsuperscript{?}, COOK Medical, Bloomington, IN).
Finally, a pre-warmed 21F cannula with a multi-hole tip
(Biomedicus\textsuperscript{?} 21F, 50~cm, Medtronic, Minneapolis, MN)
was percutaneously inserted over the stiff wire and connected to the
outflow line of the ECMO system with a monitored in-line
flow-reducer.\textbf{(Fig.~2)} Thus, while bypassing the acute failing
RV, this cannula acted as a temporary RVAD. Flow rates were optimized by
RV appearance in echocardiography and for anticoagulation the patient
received standardized heparinization. The femoral arterial outflow
cannula could be explanted after 48~h due to the competent left
ventricle using a combination of a suture-mediated percutaneous closure
device (ProGlide?, ABBOTT Vascular, CA) and a sandwiching bioabsorbable
closure device (Angioseal?, ABBOTT Vascular, CA) by reinsertion of a
guide wire through the cannula for the needed vessel access. Tricuspid
valve and pulmonary valve were without new abnormalities after
decannulation. The remaining oxygenated temporary RVAD was successfully
explanted at day 8 after implantation. Thereafter, the patient recovered
well, was awake and extubated, and could be discharged for further
medical therapy on day 21. After establishment of proper medical therapy
(sildenafil and macitentan) for precapillary idiopathic type I PAH the
patient is doing well, he is currently in NYHA class II one year after
the ECMO therapy and the coronary artery disease was decided for
conservative treatment at present.

\textbf{Comment}

Functional improvement of the RV after normalization of loading
conditions under the support of temporary RVAD systems has been
described but were rarely used in cases of isolated acute-on-chronic
s-RVF due to rapidly exacerbated PAH and is still
controversial.\textsuperscript{4,} \textsuperscript{5} Despite an
extremely high PAP in our patient, we saw no signs of pulmonary edema or
hemorrhage.

This case demonstrates a successful two-step treatment of a patient with
acute-on-chronic RVF due to severe primary PAH with implantation of a
percutaneous RVAD system combined with a regular veno-arterial ECMO
set-up for biventricular support in on-going resuscitation which may be
a safe and feasible treatment for patients with these critical clinical
conditions, however, further clinical investigation is required.

\emph{References}

1. Dandel M, Hetzer R. Temporary assist device support for the right
ventricle: pre-implant and post-implant challenges. Heart Fail Rev
2018;23:157-171.

2. Cassady S, Ramani GV. Right Heart Failure in Pulmonary Hypertension.
Cardiol Clin 2020;38:243-255.

3. Savale L, Weatherald J, Ja\selectlanguage{ngerman}ïs X, et al. Acute decompensated pulmonary
hypertension. Eur Respir Rev. 2017;26:170092.

4. Lorusso R, Raffa GM, Heuts S, et al. Pulmonary artery cannulation to
enhance extracorporeal membrane oxygenation management in acute cardiac
failure. Interact Cardiovasc Thorac Surg. 2020;30:215-222.

5. Verbelen T, Burkhoff D, Kasama K, et al. Systolic and diastolic
unloading by mechanical support of the acute vs the chronic pressure
overloaded right ventricle. J Heart Lung Transplant. 2017;36:457-465.

\emph{Figure Legends}

\textbf{Figure 1:} Initial venous-arterial-venous/pulmonary artery ECMO
setup. Inflow: blue line, Outflow: red line.

\textbf{Figure 2:} Step-wise approach of the pulmonary artery
cannulation.

\textbf{Video:} Percutaneous deployment of the 21F outflow cannula via
internal jugular vein to the pulmonary trunk.\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

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\end{figure}\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

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\end{figure}

\textbf{Hosted file}

\verb`Video-Figure.mp4`  available at \url{https://authorea.com/users/400224/articles/512561-dual-outflow-extracorporeal-membrane-oxygenation-support-in-secondary-right-ventricular-failure}

\selectlanguage{english}
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