Case
A previously healthy man in his 50s presented with rapidly increasing shortness of breath despite empiric antibiotic treatment for presumed pneumonia. Computed tomogram of the chest was notable for diffuse “ground glass” opacities. Infectious disease workup was unrevealing and he was diagnosed with acute on chronic respiratory failure resulting from dermatomyositis-associated interstitial lung disease. Progressive hypoxia refractory to mechanical ventilation necessitated veno-venous extra-corporeal membrane oxygenation (VV ECMO) using the ProtekDuo dual-lumen cannula (LivaNova, Boston, MA). In its standard configuration, de-oxygenated blood is drained from the right atrium while oxygenated blood is ejected into the main pulmonary artery and it serves as both Right ventricular support/ ECMO (RVS/ECMO) cannula. End-stage lung disease was established and, as part of lung transplant evaluation, he underwent left heart catheterization and coronary angiography. The left coronary artery angiogram revealed mild luminal irregularities. The right coronary artery (RCA) angiogram is shown in Figure 1 (Please also see Supplemental Video 1).
Figure 1.
LAO-cranial projection of the right coronary artery angiogram, at systole and diastole
What would you do next?
No further evaluation pre-operatively needed given distal RCA lesion and low revised cardiac risk index
Perform fractional flow reserve (FFR) to evaluate distal RCA lesion
Reposition cannula and repeat angiogram
Give intra-coronary nitroglycerin and repeat angiogram to rule-out coronary vasospasm
Discussion
Diagnosis
RCA compression by the right ventricular angulation of the RVS/ECMO cannula.
What to Do Next
C. Reposition cannula and repeat angiogram (Figure 2, Supplemental Video 2)
Figure 2.
LAO-cranial projection of right coronary artery after retraction of RVS/ECMO cannula, at systole and diastole
The key to the diagnosis is recognizing the potential of cannulas within the right ventricle to compress the RCA. While this may not be clinically significant, as in the present case, it may result in malignant arrhythmias or myocardial infarction. Failure to recognize and correct this phenomenon may lead to unnecessary procedures such as a coronary intervention.
Discussion
Since patient mobilization prior to lung transplantation improves post-transplant outcomes, dual-lumen cannulas such as ProtekDuo placed from the right internal jugular vein are increasingly utilized for VV ECMO.i,ii,iii The most common complications of VV ECMO include vascular injury, bleeding, and hemolysis,ii,iv but myocardial infarction secondary to coronary artery compression has been described.v Our report illustrates how the hinge point of the RVS/ECMO cannula can compress the RCA. A U-configuration of the cannula, with a less acute angle, is less likely to cause this than a more acute V-configuration. If a V-shape is recognized after advancing the distal tip of the cannula to the desired position, we advise retracting the cannula under fluoroscopic guidance which attenuates the angle at the hinge point of the cannula.
Patient Outcome
The RVS/ECMO cannula was repositioned at the time of catheterization. The patient remained hemodynamically stable without cardiac complaints. He subsequently underwent successful lung transplantation.
Clinical bottom line
Veno-venous extracorporeal membrane oxygenation with dual-lumen cannulas is increasingly utilized to promote pre- and post-op mobilization of lung transplant patients
Cannulas in the right ventricle may cause extrinsic compression of the right coronary artery
Coronary artery compression is more likely when the cannula angulation assumes a more acutely-angled V-shape rather than a less acutely angled U-shape, and the cannula should be repositioned in these circumstances
Supplementary Material
Supplemental Video 1. Compression of the right coronary artery angiogram at systole and diastole
Supplemental Video 2. Projection of right coronary artery after retraction of RVS/ECMO cannula, at systole and diastole
Acknowledgement
AB was supported by the National Institutes of Health, NIH HL145478, HL147290, and HL147575. All funds were used for the design and conduct of the study; collection, management, analysis, interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication. The authors are thankful to Ms. Elena Susan for formatting and submission of the manuscript to the journal.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Video 1. Compression of the right coronary artery angiogram at systole and diastole
Supplemental Video 2. Projection of right coronary artery after retraction of RVS/ECMO cannula, at systole and diastole