Strategies to Avoid RV Failure While on VV ECMO

Introduction: RV failure (RVF) occurs during ARDS in 10-50% of cases and may occur at even higher rates once on V-V ECMO. It decreases survival and may require conversion of V-V ECMO to alternative configurations such as V-A, V-AV or V-PA which is further associated with lower survival. We believe that our strategy using APRV-TCAV to restore lung volume at FRC and allow spontaneous breathing, and our use of inhaled pulmonary vasodilators to continue during the initial 48 hours on ECMO avoids RVF


Methods: Using our prospectively completed ECLS registry, we identified the past 50 patients requiring V-V ECMO; we then used the EMR for gathering additional data. We looked for evidence of RVF by echocardiography and for evidence of recirculation, as well as the need for ECMO reconfiguration.


Results: Average age 41.6 (range 17 -76); men 28/women 22; Etiology of ARDS: medical 34 (COVID-19 11, Flu-A 9, Legionella 2, PJP 2, Aspiration 4, Severe CAP 5, Asthma 1), trauma 13 (blunt 12, penetrating 1), surgical 2, OB 1; Length of Time on ECMO 14.6 days; four patients (8%) developed RVF with evidence of recirculation, three due to periods of significantly reducing MV support while intensifying ECMO support in attempts to resolve broncho-pleural fistulas that were eventually successfully managed using Independent Lung Ventilation with resolution of recirculation, and one patient who developed fungemia with MOF due to aplastic crisis of her acute chest syndrome (these cultures only resulted positive after cannulation). No patients received conversion of ECMO configuration.


Conclusions: Our rate of RVF was lower than the reported literature and we had no cases requiring ECMO reconfiguration that according to ELSO occurs in 2.4 – 4.1% of all V-V cases but up to 21% in some studies. Our use of APRV-TCAV and its associated supported spontaneous breathing while avoiding paralytics and deep sedation, as well as bridging with inhaled prostacyclin during the initial 48 hours on ECMO appear to reduce clinically significant RVF and the need to convert from V-V ECMO to V-A or hybrid forms.