Veno-Venous Extracorporeal Membrane Oxygenation Cannulation in Prone Position

A 54-year-old woman was referred for veno-venous extracorporeal oxygenation membrane (VV-ECMO) due to refractory hypoxic respiratory failure caused by COVID-19, despite mechanical ventilation and prolonged prone positioning. Upon arrival, placing her in a supine position resulted in severe oxygen desaturation. It was decided to cannulate her in a prone position using a dual lumen cannula.

The patient was placed face-down on the catheterization table using a dedicated prone cushion (Goebertus Trading BV), with the head in a neutral position supported by a headrest (Mediborgh) (Figure 1A). A pre-existing line in the right internal jugular vein was exchanged for an 8 French (F) sheath (Figure 1B). A 6-F Judkins R coronary catheter was advanced into the inferior vena cava (Figure 1C) and exchanged for a stiff wire (Figure 2A). A 28-F Crescent cannula (Medtronic) was inserted under fluoroscopy (Figure 2B) and connected to a Cardiohelp ECMO system (Getinge). Poor visualization of the diaphragm cusps and cardiac silhouette prevented the use of the radiopaque markers. Therefore, the arterial tubing was kept anteriorly during cannula insertion to adequately orientate the reinfusion port (Figure 2A), while advancing the tip of the cannula distally into the inferior vena cava (Figure 2B). After returning the patient to supine position, final cannula position was determined by transthoracic echocardiography by pulling back the cannula until the return jet faced the tricuspid valve (Figure 2C). There were no procedural complications. Seven days later, treatment was discontinued due to poor neurological prognosis.

This case presents an alternative for VV-ECMO cannulation in critically ill patients who cannot be cannulated using standard supine positioning.

Affiliations and Disclosures

From the ¹Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; ²Department of Intensive Care, Leiden University Medical Center, Leiden, the Netherlands.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Jose M. Montero-Cabezas. Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, the Netherlands. Email: J.M.Montero_Cabezas@lumc.nl