Veno-veno-arterial extracorporeal membrane oxygenation for respiratory failure with severe haemodynamic impairment: technique and early outcomes.
OBJECTIVE
Patients with respiratory failure may benefit from veno-venous and veno-arterial extracorporeal membrane oxygenation (ECMO) support. We report on our initial experience of veno-veno-arterial (v-v-a) ECMO in patients with respiratory failure.


METHODS
Between January 2012 and February 2014, 406 patients required ECMO support at our institution. Here, we retrospectively analysed the characteristics and outcomes of patients commenced on either veno-venous or veno-arterial ECMO due to respiratory failure, and then switched to v-v-a ECMO.


RESULTS
Ten (2%) patients proceeded to v-v-a ECMO. The underlying conditions were acute respiratory distress syndrome (n = 3), end-stage pulmonary fibrosis (n = 5) and respiratory failure after major thoracic surgery (n = 1) and Caesarean section (n = 1). In all of these patients, ECMO was initially started as veno-venous (n = 9) or veno-arterial (n = 1) ECMO but was switched to a veno-veno-arterial (v-v-a) approach after a mean of 2 (range, 0-7) days. Reasons for switching were: haemodynamic instability (right heart failure, n = 5; pericardial tamponade, n = 1; severe mitral valve regurgitation, n = 1; haemodynamic instability following cardiopulmonary resuscitation, n = 1 and evidence of previously unknown atrial septal defect with pulmonary hypertension and Eisenmenger syndrome, n = 1) and upper-body hypoxaemia (n = 1). ECMO-related complications were bleeding (n = 3) and leg ischaemia (n = 2). Seven patients were successfully taken off ECMO with 4 being bridged to recovery and a further 3 to lung transplantation after a mean of 11 (range, 9-18) days. Five patients survived until hospital discharge and all of them were alive at the end of the follow-up.


CONCLUSIONS
Veno-veno-arterial ECMO is a technically feasible rescue strategy in treating patients presenting with combined respiratory and haemodynamic failure.
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany ius.fabio@mh-hannover.de ius.r@libero.it.
Fabio
F
Ius
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany German Centre for Lung Research (DZL), Hannover, Germany.
Wiebke
W
Sommer
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Igor
I
Tudorache
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Murat
M
Avsar
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Thierry
T
Siemeni
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Jawad
J
Salman
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Jakob
J
Puntigam
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Joerg
J
Optenhoefel
Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
Mark
M
Greer
German Centre for Lung Research (DZL), Hannover, Germany Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
Tobias
T
Welte
Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
Olaf
O
Wiesner
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany German Centre for Lung Research (DZL), Hannover, Germany.
Axel
A
Haverich
German Centre for Lung Research (DZL), Hannover, Germany Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
Marius
M
Hoeper
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.
Christian
C
Kuehn
Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany German Centre for Lung Research (DZL), Hannover, Germany.
Gregor
G
Warnecke
D000328:Adult; D000368:Aged; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005240:Feasibility Studies; D005260:Female; D005858:Germany; D006439:Hemodynamics; D006801:Humans; D016040:Lung Transplantation; D008297:Male; D008875:Middle Aged; D020127:Recovery of Function; D012131:Respiratory Insufficiency / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
Extracorporeal membrane oxygenation; Haemodynamic failure; Lung transplantation; Recovery; Respiratory failure