A novel strategy to improve systemic oxygenation in venovenous extracorporeal membrane oxygenation: The “χ-configuration”

Background

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used in refractory acute respiratory distress syndrome where lung recovery is the primary goal. For its achievement, adequate extracorporeal blood flow and a maximal separation between oxygenated (inflow) and deoxygenated (outflow) blood flow are essential for reducing the recirculation phenomenon. We introduce the χ-configuration, a new cannulation strategy for VV-ECMO.

Patients and Methods

We report our experience with 30 VV-ECMO consecutive patients: in 16 patients (group NS) we applied the χ-configuration, which consists of a particular right atrial cannula arrangement and a self-made modified inflow cannula, consisting of an outflow multihole venous cannula that was inserted percutaneously through the right femoral vein, into the right atrium, just below on the superior vena cava, and a self-made modified curved inflow cannula (inserted percutaneously through the right internal jugular vein) that, in its terminal segment, permitted the tip to be positioned close to the tricuspid valve. In 14 patients (group C) we applied the standard femoro-jugular VV-ECMO 2-cannula setting. In both groups, efficacy of blood oxygenation was obtained by gas–blood analysis, by blood samples obtained at arterial, central venous, and pulmonary artery lines, and by ECMO inflow and outflow lines. The recirculation fraction was obtained by a specific bedside formula.

Results

No differences were noted between groups regarding the pre-ECMO patient characteristics. No complications during cannulation were recorded. In group NS, on-ECMO time, post-ECMO mechanical ventilation time, and ECMO overall results were significantly better than in group C. During high-flow VV-ECMO, pulmonary and systemic arterial oxygen saturation and arterial oxygen tension were significantly higher in group NS, and blood recirculation fraction was significantly lower.

Conclusions

Our data indicate that χ-configuration can be safe, feasible, and more effective than conventional VV-ECMO. It permits near complete drainage of the desaturated blood and a preferential oxygenated blood inflow toward the tricuspid valve, resulting in a significant reduction of recirculation, thereby improving the patient’s oxygenation. Our innovative strategy reduces on-ECMO and post-ECMO mechanical ventilation time, gives a faster and better pulmonary recovery, improves survival, and can reduce hospital costs.

CTSNet classification: 12, 27, 28

Abbreviations and Acronyms: BRF, blood recirculation fraction, CESAR, Conventional ventilation or ECMO for Severe Adult Respiratory failure, CO, cardiac output, ECMO, extracorporeal membrane oxygenation, Fio₂, inspired oxygen fraction, Paco₂, arterial carbon dioxide tension, SVC, superior vena cava, SARF, severe acute respiratory failure, VILI, ventilator lung injury, VV-ECMO, venovenous extracorporeal membrane oxygenation