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Right Ventricular Loop Indicating Malposition of J-wire Introducer for Double Lumen Bicaval Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) Cannula
CLINICAL SPOTLIGHT
Heart, Lung and Circulation (2014) 23, e4–e7 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2013.05.643
Right Ventricular Loop Indicating Malposition of J-wire Introducer for Double Lumen Bicaval Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) Cannula Konstantin Yastrebov, MBBS (Hons), PhD, FCICM, FACRRM, DDUa*, Con Manganas, MBBS, MS, FRACSb, Tejo Kapalli, MBBS, MDc, Sheen Peeceeyen, MBBS, MCh FRACSd a
Department of Intensive Care Medicine, St. George Hospital, Conjoint Associate Professor UNSW, Australia Department of Cardiothoracic Surgery, St. George Hospital, Clinical Associate Professor, Graduate School of Medicine, University of Wollongong, NSW, Australia c Department of Intensive Care Medicine, St. George Hospital, Australia d Department of Cardiothoracic Surgery, St. George Hospital, Australia b
Received 18 April 2013; accepted 22 May 2013; online published-ahead-of-print 21 June 2013
The key to safe placement of a bicaval double lumen cannula for Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) is to visualise correct guide wire placement in the inferior vena cava (IVC), thus aiding subsequent correct advancement of the cannula. Transoesophageal (TOE) and transthoracic (TTE) echocardiography, as well as fluoroscopy, have been described as aiding imaging techniques. We report a case of guide wire malposition into the right ventricle, despite echocardiographic confirmation of guide wire position deep into the IVC. This malposition, if undetected, may have resulted in potential life threatening complications. Keywords
Venovenous Extracorporeal Membrane Oxygenation Bicaval double lumen ‘Avalon’ cannula Transoesophageal and transthoracic echocardiography Malposition
Introduction Venovenous Extracorporeal Membrane Oxygenation is an integral part of modern management of severe refractory respiratory failure. Dual lumen single catheter technique is being increasingly utilised since the introduction of the Avalon cannula (Avalon Laboratories, Rancho Dominguez, CA) into clinical practice [1,2]. The insertion of the Avalon cannula is usually performed via right internal jugular (RIJ) vein cannulation, utilising a Seldinger technique with J-guide wire available as a part of the Avalon kit. Sequential dilation
over the guide wire is used prior to the insertion of the cannula. Adequate positioning of the cannula is achieved when the distal drainage port is located in the inferior vena cava below the hepatic veins. The proximal drainage port is located in the superior vena cava (SVC), and the return port in the right atrium (RA) with the flow directed towards the tricuspid valve. The insertion of a large Avalon cannula up to 31FG in diameter and over 30 cm in length has been associated with complications such as right ventricular rupture, tamponade, and inadvertent cannulation of the coronary sinus or the
* Corresponding author at: ICU, Level 2, Tower Block, Gray Street, The St. George Hospital, Kogarah, NSW 2217, Australia. Tel.: +61 02 9113 3373; fax: +61 02 9113 1561., Email: [email protected] © 2013 Published by Elsevier Inc on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
e5
Figure 1 TOE, mid-oesophageal window. 2D imaging used to Track guide wire entering right atrium from the SVC.
hepatic veins [3,4]. These complications arise primarily due to malposition of the guide wire and subsequent cannula insertion. Current literature describes several techniques such as pressure-guidance, fluoroscopy and echocardiography [5–7] to guide optimal Avalon cannula placement, however there is no comparative data to assess superiority of one technique over the other. Echocardiography has multiple advantages in the critical care setting, combining a readily available bedside modality with good accuracy in emergency situations.
Case Report A 43 year-old male was admitted to our Intensive Care Unit due to severe hypoxaemic respiratory failure with the diagnosis of community acquired pneumonia. Chest X-rays
Figure 2 TOE, mid-oesophageal 2D imaging of the superior cava-atrial junction. Guide wire seen "in-plane’’ with 2D ultrasound beam, entering RV, while an off plane loop of the guide wire is seen as a separate reverberation artefact further within RA cavity.
demonstrated extensive bilateral diffuse infiltrates. Rapid clinical deterioration occurred in spite of conventional invasive ventilation and adjunctive supportive measures. A trial of ventilation with high frequency oscillation as a potential rescue measure failed to improve oxygenation. In view of ongoing refractory hypoxaemia, VVECMO was indicated and instituted. VV ECMO with bicaval double-lumen cannulation (Avalon, Ranco Dominguez, CA, USA) via the SVC was performed. A J-tipped 0.03800 210 cm guide wire was threaded via the right internal jugular vein following venepuncture. The progression of the guide wire in the terminal SVC and RA was followed with TEE imaging (Fig. 1). An uncertainty in guide wire position was experienced while imaging the right atrium in the bicaval TEE plane (Fig. 2). The IVC could not be imaged with TEE beyond the inferior cavoatrial junction due to the patient’s body habitus. Our optimal imaging technique combines TOE and TTE planes to obtain superior imaging of the guide wire, and subsequent cannula position within cardiac chambers and in the great veins. Subcostal transthoracic echocardiographic windows offered excellent views of the IVC in our patient. The guide wire was clearly identified in the IVC, well below the hepatic vein (Fig. 3). It was unclear if the right atrial part of the guide wire on this image was in fact a grating lobe artefact. However, further careful analysis of the images revealed an additional artefact within the right atrium, raising suspicion of a guide wire loop. It appeared that one part of the loop possibly appeared "in-plane’’ with the 2D ultrasound beam, while another traversed "off-plane’’ with the ultrasound beam producing a reverberation artefact (Fig. 4). Further scanning via TTE subcostal views and four-chamber TOE views confirmed that the guide wire had entered the
Figure 3 TTE subcostal window – initial impression of guide wire adequate position by clear identification of the wire well within IVC. Uncertainty experienced as to the possible grating lobe artefact produced by the guide wire within right atrium. Second moving artefact then noted raising suspicion of the presence of the guide wire loop.
e6
Figure 4 TOE, mid-oesophageal window, 2D slightly modified bicaval view. Part of the guide wire appeared "in-plane’’ with 2D ultrasound beam, while another is seen traversing the 2D plane creating a reverberation artefact.
right atrium (RA) from the superior vena cava and then was deflected by the inferior RA wall towards the tricuspid valve, entering the right ventricle (RV) (Figs. 5 and 6). The wire then looped inside the RV and exited the tricuspid valve posteriorly back into the RA travelling "successfully’’ into the IVC and creating false initial impression of a correct position, suitable for cannulation. The wire was then withdrawn, and multiple unsuccessful attempts were made to re-introduce it into the IVC without experiencing RV looping. The difficult anatomical alignment of SVC and IVC in this patient repeatedly hampered the advancement of soft J-guide wire into the IVC. At this stage the original guide wire was exchanged for a stiffer vascular guide wire (Amplatz super stiff straight tip 0.035 in. 180 cm Emerald guide wire) [8]. Following quick manipulation under ultrasound guidance the new guide wire was successfully
Figure 5 TOE, 2D Mind-oesophageal 4 chamber view. Guide wire is clearly visualised entering right ventricle from RA via TV.
K. Yastrebov et al.
Figure 6 TOE 2D mid-oesophageal window – RV inflow and outflow plane. Loop of the J-guide wire is identified within RV outflow tract.
placed into the IVC which was followed by an uneventful sequential dilatation and accurate cannula placement (Figs. 7 and 8).
Discussion This case illustrates the need for meticulous imaging guidance during guide wire insertion prior to placement of a double-lumen bicaval cannula for VV ECMO. Malposition of the J-guide wire and looping of the guide wire in the right ventricle occurred in our case despite echocardiographic
Figure 7 TTE subcostal window. Correct position of the Emerald guide wire successfully crossing RA straight from SVC to the IVC without loop.
e7
Figure 8 CXR following successful placement of double lumen bicaval Avalon cannula.
monitoring. A false impression of adequate wire position was created by observation of the wire within the IVC below hepatic veins. The guide wire loop in the right ventricle, if undetected, would have been followed by serial dilatations and cannula insertion over the guide wire, possibly resulting in perforation of the right atrium, right ventricle and/or the tricuspid valve, with likely life threatening consequences. TOE allows unprecedented bed-side imaging of the distal SVC and right atrium. However, TOE often provides inadequate imaging of the sub-diaphragmatic IVC due to the natural curvature of the terminal oesophagus away from IVC below the diaphragm. Transthoracic echocardiography, via subcostal views, mostly allows good imaging of right atrium, inferior cavo-atrial junction, distal IVC and hepatic veins. We believe the combination of TOE and TTE allows better tracking of the guide wire, and may prevent potentially lifethreatening cannula malposition. Rapid guide wire manipulation should be avoided thus allowing continuous tracking of the wire tip with ultrasound imaging. Additional views and planes of interrogation of all right heart chambers should be used prior to the insertion of a large cannula to ensure absence of guide wire loops. Special attention should be paid to interpretation of unusual echocardiographic artefacts within cardiac chambers as a possible sign of guidewire malposition. In conclusion, combination TOE and TTE echocardiographic imaging is the optimum modality to guide adequate placement of Bicaval Double Lumen catheters for VV ECMO. To ensure correct placement of a guide wire, it is important to use multiple views combining unique opportunities offered by both transoesophageal and transthoracic 2D echocardiography. Cautious interpretation of the images and meticulous
Figure 9 TTE, subcostal window, 3D imaging. Avalon cannula is seen well positioned in RA and IVC beyond hepatic venous junction.
attention to possible artefacts arising from loops of the guide wire may avoid subsequent disastrous cannula malposition. Future improvements in live 3D echocardiographic temporal and spatial resolution may help to overcome existing limitations of 2D imaging and offer new opportunities in guiding positioning of bicaval ECMO cannulas (Fig. 9).
References [1] Bermudez CA, Rocha RV, Sappington PL, Toyoda Y, Murray HN, Boujoukos AJ. Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults. Ann Thorac surg 2010;90(Sep (3)):991–5. [2] Javidfar J, Brodie D, Wang D, Ibrahimiye AN, Yang J, Zwischenberger JB, et al. Use of bicaval dual-lumen catheter for adult venovenous extracorporeal membrane oxygenation. Ann Thorac Surg 2011;91:1763–8. [3] Reis Miranda D, Dabiri Abkenari L, Nieman K, Dijkshoorn M, Duckers E, Gommers D. Myocardial infarction due to malposition of ECMO cannula. Intensive Care Med 2012;38:1233–4. [4] Hirose H, Yamane K, Marhefka G, Cavarocchi N. Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation. J Cardiothorac Surg 2012;7:36. [5] Javidfar J, Wang D, Zwischenberger JB, Costa J, Mongero L, Sonett J, et al. Insertion of bicaval dual-lumen extracorporeal membrane oxygenation catheter with image guidance. ASAIO J 2011;57:203–5. [6] Dolch ME, Frey L, Buerkle MA, Weig T, Wassilowsky D, Irlbeck M. Transesophageal echocardiography-guided technique for extracorporeal membrane oxygenation dual-lumen catheter placement. ASAIO J 2011;57 (Jul–Aug (4)):341–3. [7] Langer T, Vecchi V, Belenkiy SM, Cancio LC, Gattinoni L. Pressureguided positioning of bicaval dual-lumen catheters for venovenous extracorporeal gas exchange. Intensive Care Med 2013;39(Jan (1)):151–4. [8] Trimlett RH, Cordingley JJ, Griffiths MJ, Price S, Hunter DN, Finney SJ. A modified technique for insertion of dual lumen bicaval cannulae for venovenous extracorporeal membrane oxygenation. Intensive Care Med 2011;37:1036–7.
Heart, Lung and Circulation (2014) 23, e4–e7 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2013.05.643
Right Ventricular Loop Indicating Malposition of J-wire Introducer for Double Lumen Bicaval Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) Cannula Konstantin Yastrebov, MBBS (Hons), PhD, FCICM, FACRRM, DDUa*, Con Manganas, MBBS, MS, FRACSb, Tejo Kapalli, MBBS, MDc, Sheen Peeceeyen, MBBS, MCh FRACSd a
Department of Intensive Care Medicine, St. George Hospital, Conjoint Associate Professor UNSW, Australia Department of Cardiothoracic Surgery, St. George Hospital, Clinical Associate Professor, Graduate School of Medicine, University of Wollongong, NSW, Australia c Department of Intensive Care Medicine, St. George Hospital, Australia d Department of Cardiothoracic Surgery, St. George Hospital, Australia b
Received 18 April 2013; accepted 22 May 2013; online published-ahead-of-print 21 June 2013
The key to safe placement of a bicaval double lumen cannula for Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) is to visualise correct guide wire placement in the inferior vena cava (IVC), thus aiding subsequent correct advancement of the cannula. Transoesophageal (TOE) and transthoracic (TTE) echocardiography, as well as fluoroscopy, have been described as aiding imaging techniques. We report a case of guide wire malposition into the right ventricle, despite echocardiographic confirmation of guide wire position deep into the IVC. This malposition, if undetected, may have resulted in potential life threatening complications. Keywords
Venovenous Extracorporeal Membrane Oxygenation Bicaval double lumen ‘Avalon’ cannula Transoesophageal and transthoracic echocardiography Malposition
Introduction Venovenous Extracorporeal Membrane Oxygenation is an integral part of modern management of severe refractory respiratory failure. Dual lumen single catheter technique is being increasingly utilised since the introduction of the Avalon cannula (Avalon Laboratories, Rancho Dominguez, CA) into clinical practice [1,2]. The insertion of the Avalon cannula is usually performed via right internal jugular (RIJ) vein cannulation, utilising a Seldinger technique with J-guide wire available as a part of the Avalon kit. Sequential dilation
over the guide wire is used prior to the insertion of the cannula. Adequate positioning of the cannula is achieved when the distal drainage port is located in the inferior vena cava below the hepatic veins. The proximal drainage port is located in the superior vena cava (SVC), and the return port in the right atrium (RA) with the flow directed towards the tricuspid valve. The insertion of a large Avalon cannula up to 31FG in diameter and over 30 cm in length has been associated with complications such as right ventricular rupture, tamponade, and inadvertent cannulation of the coronary sinus or the
* Corresponding author at: ICU, Level 2, Tower Block, Gray Street, The St. George Hospital, Kogarah, NSW 2217, Australia. Tel.: +61 02 9113 3373; fax: +61 02 9113 1561., Email: [email protected] © 2013 Published by Elsevier Inc on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).
e5
Figure 1 TOE, mid-oesophageal window. 2D imaging used to Track guide wire entering right atrium from the SVC.
hepatic veins [3,4]. These complications arise primarily due to malposition of the guide wire and subsequent cannula insertion. Current literature describes several techniques such as pressure-guidance, fluoroscopy and echocardiography [5–7] to guide optimal Avalon cannula placement, however there is no comparative data to assess superiority of one technique over the other. Echocardiography has multiple advantages in the critical care setting, combining a readily available bedside modality with good accuracy in emergency situations.
Case Report A 43 year-old male was admitted to our Intensive Care Unit due to severe hypoxaemic respiratory failure with the diagnosis of community acquired pneumonia. Chest X-rays
Figure 2 TOE, mid-oesophageal 2D imaging of the superior cava-atrial junction. Guide wire seen "in-plane’’ with 2D ultrasound beam, entering RV, while an off plane loop of the guide wire is seen as a separate reverberation artefact further within RA cavity.
demonstrated extensive bilateral diffuse infiltrates. Rapid clinical deterioration occurred in spite of conventional invasive ventilation and adjunctive supportive measures. A trial of ventilation with high frequency oscillation as a potential rescue measure failed to improve oxygenation. In view of ongoing refractory hypoxaemia, VVECMO was indicated and instituted. VV ECMO with bicaval double-lumen cannulation (Avalon, Ranco Dominguez, CA, USA) via the SVC was performed. A J-tipped 0.03800 210 cm guide wire was threaded via the right internal jugular vein following venepuncture. The progression of the guide wire in the terminal SVC and RA was followed with TEE imaging (Fig. 1). An uncertainty in guide wire position was experienced while imaging the right atrium in the bicaval TEE plane (Fig. 2). The IVC could not be imaged with TEE beyond the inferior cavoatrial junction due to the patient’s body habitus. Our optimal imaging technique combines TOE and TTE planes to obtain superior imaging of the guide wire, and subsequent cannula position within cardiac chambers and in the great veins. Subcostal transthoracic echocardiographic windows offered excellent views of the IVC in our patient. The guide wire was clearly identified in the IVC, well below the hepatic vein (Fig. 3). It was unclear if the right atrial part of the guide wire on this image was in fact a grating lobe artefact. However, further careful analysis of the images revealed an additional artefact within the right atrium, raising suspicion of a guide wire loop. It appeared that one part of the loop possibly appeared "in-plane’’ with the 2D ultrasound beam, while another traversed "off-plane’’ with the ultrasound beam producing a reverberation artefact (Fig. 4). Further scanning via TTE subcostal views and four-chamber TOE views confirmed that the guide wire had entered the
Figure 3 TTE subcostal window – initial impression of guide wire adequate position by clear identification of the wire well within IVC. Uncertainty experienced as to the possible grating lobe artefact produced by the guide wire within right atrium. Second moving artefact then noted raising suspicion of the presence of the guide wire loop.
e6
Figure 4 TOE, mid-oesophageal window, 2D slightly modified bicaval view. Part of the guide wire appeared "in-plane’’ with 2D ultrasound beam, while another is seen traversing the 2D plane creating a reverberation artefact.
right atrium (RA) from the superior vena cava and then was deflected by the inferior RA wall towards the tricuspid valve, entering the right ventricle (RV) (Figs. 5 and 6). The wire then looped inside the RV and exited the tricuspid valve posteriorly back into the RA travelling "successfully’’ into the IVC and creating false initial impression of a correct position, suitable for cannulation. The wire was then withdrawn, and multiple unsuccessful attempts were made to re-introduce it into the IVC without experiencing RV looping. The difficult anatomical alignment of SVC and IVC in this patient repeatedly hampered the advancement of soft J-guide wire into the IVC. At this stage the original guide wire was exchanged for a stiffer vascular guide wire (Amplatz super stiff straight tip 0.035 in. 180 cm Emerald guide wire) [8]. Following quick manipulation under ultrasound guidance the new guide wire was successfully
Figure 5 TOE, 2D Mind-oesophageal 4 chamber view. Guide wire is clearly visualised entering right ventricle from RA via TV.
K. Yastrebov et al.
Figure 6 TOE 2D mid-oesophageal window – RV inflow and outflow plane. Loop of the J-guide wire is identified within RV outflow tract.
placed into the IVC which was followed by an uneventful sequential dilatation and accurate cannula placement (Figs. 7 and 8).
Discussion This case illustrates the need for meticulous imaging guidance during guide wire insertion prior to placement of a double-lumen bicaval cannula for VV ECMO. Malposition of the J-guide wire and looping of the guide wire in the right ventricle occurred in our case despite echocardiographic
Figure 7 TTE subcostal window. Correct position of the Emerald guide wire successfully crossing RA straight from SVC to the IVC without loop.
e7
Figure 8 CXR following successful placement of double lumen bicaval Avalon cannula.
monitoring. A false impression of adequate wire position was created by observation of the wire within the IVC below hepatic veins. The guide wire loop in the right ventricle, if undetected, would have been followed by serial dilatations and cannula insertion over the guide wire, possibly resulting in perforation of the right atrium, right ventricle and/or the tricuspid valve, with likely life threatening consequences. TOE allows unprecedented bed-side imaging of the distal SVC and right atrium. However, TOE often provides inadequate imaging of the sub-diaphragmatic IVC due to the natural curvature of the terminal oesophagus away from IVC below the diaphragm. Transthoracic echocardiography, via subcostal views, mostly allows good imaging of right atrium, inferior cavo-atrial junction, distal IVC and hepatic veins. We believe the combination of TOE and TTE allows better tracking of the guide wire, and may prevent potentially lifethreatening cannula malposition. Rapid guide wire manipulation should be avoided thus allowing continuous tracking of the wire tip with ultrasound imaging. Additional views and planes of interrogation of all right heart chambers should be used prior to the insertion of a large cannula to ensure absence of guide wire loops. Special attention should be paid to interpretation of unusual echocardiographic artefacts within cardiac chambers as a possible sign of guidewire malposition. In conclusion, combination TOE and TTE echocardiographic imaging is the optimum modality to guide adequate placement of Bicaval Double Lumen catheters for VV ECMO. To ensure correct placement of a guide wire, it is important to use multiple views combining unique opportunities offered by both transoesophageal and transthoracic 2D echocardiography. Cautious interpretation of the images and meticulous
Figure 9 TTE, subcostal window, 3D imaging. Avalon cannula is seen well positioned in RA and IVC beyond hepatic venous junction.
attention to possible artefacts arising from loops of the guide wire may avoid subsequent disastrous cannula malposition. Future improvements in live 3D echocardiographic temporal and spatial resolution may help to overcome existing limitations of 2D imaging and offer new opportunities in guiding positioning of bicaval ECMO cannulas (Fig. 9).
References [1] Bermudez CA, Rocha RV, Sappington PL, Toyoda Y, Murray HN, Boujoukos AJ. Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults. Ann Thorac surg 2010;90(Sep (3)):991–5. [2] Javidfar J, Brodie D, Wang D, Ibrahimiye AN, Yang J, Zwischenberger JB, et al. Use of bicaval dual-lumen catheter for adult venovenous extracorporeal membrane oxygenation. Ann Thorac Surg 2011;91:1763–8. [3] Reis Miranda D, Dabiri Abkenari L, Nieman K, Dijkshoorn M, Duckers E, Gommers D. Myocardial infarction due to malposition of ECMO cannula. Intensive Care Med 2012;38:1233–4. [4] Hirose H, Yamane K, Marhefka G, Cavarocchi N. Right ventricular rupture and tamponade caused by malposition of the Avalon cannula for venovenous extracorporeal membrane oxygenation. J Cardiothorac Surg 2012;7:36. [5] Javidfar J, Wang D, Zwischenberger JB, Costa J, Mongero L, Sonett J, et al. Insertion of bicaval dual-lumen extracorporeal membrane oxygenation catheter with image guidance. ASAIO J 2011;57:203–5. [6] Dolch ME, Frey L, Buerkle MA, Weig T, Wassilowsky D, Irlbeck M. Transesophageal echocardiography-guided technique for extracorporeal membrane oxygenation dual-lumen catheter placement. ASAIO J 2011;57 (Jul–Aug (4)):341–3. [7] Langer T, Vecchi V, Belenkiy SM, Cancio LC, Gattinoni L. Pressureguided positioning of bicaval dual-lumen catheters for venovenous extracorporeal gas exchange. Intensive Care Med 2013;39(Jan (1)):151–4. [8] Trimlett RH, Cordingley JJ, Griffiths MJ, Price S, Hunter DN, Finney SJ. A modified technique for insertion of dual lumen bicaval cannulae for venovenous extracorporeal membrane oxygenation. Intensive Care Med 2011;37:1036–7.