key: cord-0731445-c882tbeb authors: Patel, Sankalp P.; Solomon, Brian J.; Pascotto, Robert D.; D'Orazio, Stephen E.; Navas, Elsy V.; Cubeddu, Robert J.; Cudemus, Gaston A. title: Right Ventricular Failure Manifesting in COVID-19 ARDS: A Call to Transition from VV-ECMO to RVAD-ECMO date: 2022-02-26 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2022.02.026 sha: 0def8d80402d7ce70dee6b0cb21c86a5fea3d6f8 doc_id: 731445 cord_uid: c882tbeb Often labeled the forgotten ventricle, the right ventricle's (RV) importance has been magnified over the last two years as providers witness how SARS-CoV-2 infection has a predilection for exacerbating RV failure. Veno-venous extracorporeal membranous oxygenation (VV-ECMO) has become a mainstay treatment modality for a select patient population suffering from severe COVID-19 acute respiratory distress syndrome (ARDS). Concomitant early implementation of a right ventricular assist device with ECMO (RVAD-ECMO) may confer benefit in patient outcomes. The underlying mechanism of RV failure in COVID-19 has a multifactorial etiopathogenesis, nonetheless clinical evaluation of a patient necessitating RV support remains unchanged. Herein, we report a case of a critically ill patient who was transitioned from conventional VV-ECMO Medtronic® CrescentTM cannula to RVAD-ECMO with insertion of the LivaNova® ProtekDuoTM dual-lumen RVAD cannula. Approaching two years into the COVID-19 global pandemic, fatigued providers have been tasked with managing a seemingly insurmountable caseload of critically ill patients. Through utilization of a multi-disciplinary approach and adherence to standardized protocols, many institutions have demonstrated gradual improvement in outcomes as clinicians further understand the pathophysiologic basis of SARS-CoV-2 infection. The preponderance of right ventricular failure over left ventricular failure among severely infected patients stems from the elevated RV afterload with concurrent decrease in contractility, all presumably secondary to ARDS, thromboembolic disease, and direct viral penetration 1 . Advanced imaging modalities including cardiac magnetic resonance imaging (CMR) and echocardiography have also shown the incidence of RV failure exceeds LV failure in critically ill patients with COVID-19 2,3 . Timely recognition and intervention in the setting of right ventricular compromise is crucial, as these patients can decompensate rapidly. Upon identification of RV failure in a patient already on conventional VV-ECMO circuit, medical therapy in the form of offloading the RV through preload reduction, augmentation of contractility with inotropic agents, and initiation of inhaled pulmonary vasodilators should be optimized 4 . It is when medical therapy yields insufficient, and decompensation persists, that the option for further mechanical circulatory support be explored. With the advent of a dual-lumen single cannula such as the LivaNova® ProtekDuo TM , conventional VV-ECMO can be upgraded to further enhance RV support. This report describes a case in which a patient receiving conventional VV-ECMO support for 6 weeks exhibited symptomatic congestive RV failure and underwent internal jugular venous cannula exchange with insertion of a ProtekDuo TM right ventricular assist device. A 53-year-old man unvaccinated against SARS-CoV-2 with medical history significant for anxiety, hypertension, and ARDS requiring mechanical ventilation 3 years ago due to substance overdose presented from outside facility to our institution for evaluation of VV-ECMO candidacy (height: 185 cm; weight 98 kg; BMI: 29.5 kg/m 2 ). In brief, he presented to previous facility 9 days before transfer to our institution with hypoxic respiratory failure secondary to SARS-CoV-2 infection and was found to be saturating 85% on room air. Contrasted computed tomography of the chest was performed revealing expected diffuse bilateral groundglass opacities. He was subsequently placed on high-flow nasal cannula and encouraged to self-prone; however, the patient was non-compliant. Thereafter, noninvasive positive pressure ventilation (NIPPV) was provided in the form of bi-level positive airway pressure (BIPAP) with fraction of inspired oxygen (FiO2) set at 100%. The patient initially refused to be intubated, but after 3 days of worsening dyspnea evidenced through shallow, tachypneic respirations, he agreed to proceed. This occurred the day prior to transfer to our facility for VV-ECMO evaluation. Pertinent medical therapy given at outside facility included two doses of 400mg tocilizumab, 6mg dexamethasone daily for 9 days, completion of 5-day course of remdesivir, and treatment dose enoxaparin for a right axillary deep vein thrombus. On arrival to our center, initial ventilator settings witnessed were set on volume-control He continued supportive care while fine ventilator adjustments were made, and two weeks later, decision was made to transition from a two-cannula apparatus to a single dual-lumen 27Fr Crescent TM cannula configuration in the left subclavian vein with simultaneous tracheostomy, with plan to work with physical therapy and move towards rehabilitation. The transition was performed without complication, and aside from bleeding which was controlled intraoperatively due to the patient being anticoagulated for 2 weeks, he returned to the cardiovascular intensive care unit (CVICU) in hemodynamically stable condition. We attempted to wean ECMO on multiple occasions; nonetheless, the patient was unable to tolerate a sweep < 4L/min due to hypercapnia and his CT scan revealing diffusely severe lung disease ( Figure 2 ). He continued undergoing supportive care, physical therapy, and daily awakening. Given significant volume influx through multiple infusions required for sedation, anticoagulation, and inflow from VV-ECMO, the patient was intermittently on loop diuretic infusions as well; however, our focus led to the elimination of multiple infusions with time and implementing oral medications to prevent volume overload. One morning, a transient bout of hypotension and worsening hypoxia was encountered, and the patient underwent a point-of-care bedside echocardiogram, unveiling septal-D flattening (+McConnell sign) and severely reduced RV function consistent with RV volume overload. Aggressive diuresis was trialed along with pulmonary vasodilator therapy with epoprostenol, and his course was concomitantly complicated by a suspected nosocomial fungal infection corroborated by a markedly profound leukocytosis and sputum cultures (+) for Candida Albicans. The patient was placed on micafungin therapy with gradual intermittent improvement observed and was noted to be awake, alert, and oriented but extremely weak. Medical therapy for RV failure was pursued until the patient decompensated again 6 weeks into his hospital course experiencing a recurrent bout of hypotension and hypoxia in conjunction with marked elevation in liver function tests and rise in creatinine (Table 1) . Medications administered included diuresis with furosemide and initiation of inhaled epoprostenol, At this time, a repeat transthoracic echocardiogram was performed and elucidated just how severe the RV failure was. RVSP was noted to be 51mmHg, the right ventricle appeared severely enlarged, moderate tricuspid regurgitation and elevated pulmonary artery systolic pressure also now accompanied septal flattening visualized 2 weeks prior (Figure 1 ). At that juncture, a joint decision among all providers was made to exchange the current VV-ECMO Medtronic® Crescent TM dual-lumen cannula for a LivaNova® ProtekDuo TM dual-lumen RVAD cannula given the severe pulmonary dysfunction evidenced by CT scan and noted lack of reserve. With the patient receiving VV-ECMO through a single dual-lumen cannula, the complexity of decannulation and substitution with ProtekDuo TM RVAD device was not straightforward. A multidisciplinary approach led by the ECMO team was implemented, with all in agreement with establishing drainage through the right femoral vein intraoperatively, while concomitantly positioning the Crescent TM cannula into the subclavian vein to continue inflow. The challenge here encountered was attempting to simultaneously fit two 32Fr cannulas within the superior vena cava. After accessing the right femoral vein, a dilator kit was utilized to dilate from 8Fr to 24Fr, until a 25Fr long venous cannula was inserted to the IVC. The line was subsequently clamped. The Crescent TM cannula was then clamped, with the drainage remaining attached to the middle port. Under fluoroscopic guidance, the cannula was repositioned into the subclavian vein. VV-ECMO ensued successfully thereafter, and this approach opened adequate room in the SVC for the placement of the ProtekDuo tm RVAD. Ultrasound-guided access was obtained with a J-wire and exchanged for a 6Fr sheath. A Swan-Ganz catheter was inserted into the right pulmonary artery (PA) thereafter. An extra-stiff Amplatz tm wire was placed through the Swan-Ganz catheter into the right PA in preparation for dilation. Upon dilation to 26Fr under fluoroscopy, a 31Fr ProtekDuo TM cannula was inserted. After successful insertion without complications, the RVAD cannula was attached to a separate circuit. This circuit had a Quadrox-i® oxygenator linked to a LifeSPARC ® pump. The patient's saturation increased to 100% and flow was initiated at 4.5L at a rate of 7500 RPM. The patient maintained stability for 15 minutes with isolated RVAD-ECMO configuration saturating >99% SpO2. This was when subclavianfemoral VV-ECMO was decannulated and removed with adequate pressure maintained to prevent bleeding along with 3 separate compressive sutures tied with the aid of cardiothoracic surgery. He was transferred back to the CVICU hemodynamically stable for further supportive care. In only 24 hours, a significant improvement was observed in renal function, with near complete resolution of hepatic dysfunction following 2 weeks thereafter. Approximately 1month post-placement of the ProtekDuo TM dual-lumen single RVAD cannula (Fig 1) , the patient demonstrated resounding improvement in hemodynamic stability and complete resolution of congestive hepatopathy and renal failure as well (Table 1 ). Much of the data encompassing the cardiovascular complications of COVID-19 has mainly focused on arrhythmias, myocardial dysfunction, and myocardial injury involving the left heart 5 . A recent meta-analysis revealed almost one out of five patients infected with SARS-CoV-2 exhibit right ventricular dysfunction, with a threefold higher likelihood of all-cause death in comparison to subjects without RV failure 6 . The RV is the link between our systemic venous circulation and the pulmonary circuit. Lesser dense myofibrils (~1/3 density compared to LV) provide a chamber with increased compliance, permitting fluctuations in venous return. Well known, the RV exudes a complex physiological relationship between rhythm, preload, contractility, afterload, and interdependence with the LV. The supposed mechanism of RV failure in patients with COVID ARDS is likely secondary to dense lung fibrosis leading to increased RV afterload and pulmonary arterial pressures causing eventual cor pulmonale 7 . Though there is likely a multifactorial pathogenesis at play in the setting of COVID, one fact about RV failure irrespective of underlying cause, is how rapidly patients can decompensate. The medical management of RV failure involves optimization of preload and mitigating factors which may increase pulmonary vascular resistance. Once inhaled pulmonary vasodilators have been started, a patient's cardiopulmonary status is likely very precarious. This is when discussion is initiated regarding extracorporeal life support, and whether a patient is an optimal candidate 8 . The indications for initiating ECMO in COVID-19 patients have been described by Mikkelsen et al., who recommended consideration in patients with PaO2/FiO2 < 50mmHg for >3 hours, PaO2/FiO2 < 80mmHg for >6 hours, or arterial pH lower than 7.25 with PaCO2 of >60mmHg for 6 hours. Our patient met those criteria on arrival to our facility, and RV failure persisted on VV-ECMO, thus demanding need for isolated RV mechanical circulatory support. The ProtekDuo TM had its first-in-man use in 2016, in conjunction with rising popularity of the left-ventricular assist device (LVAD) with primary complications of this device being RV failure 9 . Similar to conventional VV-ECMO, the ProtekDuo TM operates through centrifugal flow, and can provide a flow of up to 4.5L/min. Upon insertion within the right internal jugular vein, there is a proximal return cannula which remains in the RA, while the remainder distal drainage lumen is fed (usually over Swan Ganz catheter) directly into the main pulmonary artery creating an RA-PA bypass tract passing the RV 10 . The advantage of the ProtekDuo TM cannula, in comparison to its competitors, is the insertion within the right IJ vein, permitting full ambulation within recipients. RVAD-ECMO with the ProtekDuo TM in patients with COVID-19 in comparison to mechanical ventilation alone has been to show to reveal no increase in secondary end-organ damage, with higher in-hospital and 30-day survival in the RVAD-ECMO cohort, leading to a conclusion to prioritize RV support in these patients 11 . RVAD-ECMO configuration with the ProtekDuo TM single dual-lumen cannula, in comparison to conventional Crescent TM VV-ECMO circuit in severely ill COVID-19 patients has not yet been studied, though our case showcases there appears to be a benefit through addition of right ventricular support. We present herein a case of remarkable hemodynamic improvement status post mechanical circulatory support implementation with the LivaNova ® ProtekDuo TM device. Our patient is currently alert, awake, and oriented to person, place and situation and is working with physical and occupational therapy regularly. He is off mechanical ventilation, tolerating regular diet, and our plan remains to have him placed at a lung transplant institution once able to walk 100-200 feet. 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