Kukielski, Casey

Abstract Background With increasing extracorporeal membrane oxygenation (ECMO) utilization over the last decade, clinicians have developed “hybrid” configurations to meet complex perfusion requirements. In the setting of differential hypoxemia, a veno‐arteriovenous (V‐AV) configuration provides oxygenated cardiac preload and hemodynamic support to satisfy physiologic demands. We aim to further characterize the patient population, indications, and outcomes associated with this hybrid configuration. Methods We retrospectively reviewed all adult patients placed on V‐AV ECMO at our institution from June 2016 to December 2019. Through a review of the electronic medical records, data describing demographic features, comorbidities, and ECMO‐specific information were analyzed systematically. Results 14 patients were placed on V‐AV ECMO during the study period. Our cohort was 79% male with a median age of 54 and BMI of 30.3. These patients had a median SOFA‐0 score of 15 and SAVE score of ‐12. Patients were treated with ECMO support for a median of 144.1 (IQR 98.5 – 183.1) hours, consisting of 0.2 (IQR 0 – 17.7) hours of VA and 92.4 (IQR 53.7 – 115.1) hours of V‐AV followed by 67.4 (IQR 20.3 – 96.6) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%). Conclusion ECMO patients with recovering left ventricular function and persistent gas exchange abnormalities are at risk for developing differential hypoxemia. We describe an approach to utilizing V‐AV configuration when the likelihood of differential hypoxemia is extremely high, with a survival rate that compares favorably to Extracorporeal Life Support Organization statistics and published case series.

Patients in respiratory failure on VV ECMO may develop cardiovascular dysfunction necessitating additional hemodynamic support, while patients in cardiovascular failure on VA ECMO may require additional respiratory support for concurrent gas exchange abnormalities. A hybrid venoarterio-venous (VA-V) configuration provides both cardiac support via a traditional arterial reinfusion cannula and respiratory support via an additional venous reinfusion limb. We describe our single center experience using VA-V ECMO for patients (n = 14, median age 54) with combined cardiopulmonary failure or differential hypoxemia. Patients were treated with ECMO support for a median of 148.2 (IQR 122.6 – 174.4) hours, consisting of 0 (IQR 0 – 1.8) hours of VA and 92.4 (IQR 58 – 115) hours of VA-V followed by 46 (IQR 0 – 95.5) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%).