Would your ECMO Program consider VV ECMO for CDH Patients? There is much discussion surrounding the most appropriate type of ECMO for a patient with congenital diaphragmatic hernia (CDH). Take below as an example case study and see the reasons why one would argue VV may be a very appropriate form of ECMO for this diagnosis.
A neonate is being admitted to your facility with respiratory failure secondary to a diagnosis of Left congenital diaphragmatic hernia. The patient is on HFOV, INO, Dopamine at 20 mcg/kg/min, and Epi at 0.2 mcg/kg/min. Despite being on maximal vent settings your patient’s Oxygen Index remains >40 with pre-ductal sats in the 70’s. ECHO shows no heart defects, good squeeze, but severe PPHN. The new attending physician with very little ECMO experience is debating whether to place the patient on VV or VA ECMO. From your experience you explain to the physician the pros of VV ECMO.
1. You maintain the native heart function by maintaining natural blood flow through the lungs.
2. The patient does not truly need heart support in the form of VA ECMO as the patient’s heart is structurally intact and has good function.
3. Oxygen is a very powerful drug and once the heart and body is adequately oxygenated you will most likely be able to dramatically wean down, if not off of, the vasoactive dips.
4. By using VA ECMO you risk the heart going into stun.
5. Only one vessel will have to be to be manipulated with VV ECMO and carotid artery will not have to be ligated once the patient is weaned off ECMO.
6. VV ECMO can adequately supply the oxygen needed to fully support this patient as long as an adequate size cannula can be placed. Some ECMO Centers may also consider a cephalad cannula for added drainage.
7. Studies have shown VA ECMO for CDH’s had higher neurologic morbidity than VV ECMO.
The physician has listened to your advice and has decided to place the patient on VV ECMO with a double lumen cannula. Cannulation is uneventful and the patient is now on full flow of 150ml/kg/min with his sats in the 90’s. The patient has been transitioned from HFOV to conventional vent. Epi was turned off almost immediately and over the next several hours Dopamine was weaned down to 8mcg/kg/min.