Application of veno-arterial-venous extracorporeal membrane oxygenation in differential hypoxia

Abstract

Veno-arterial extracorporeal membrane oxygenation (ECMO) through the femoral vein and artery may cause differential hypoxia, i.e., lower PaO2 in the upper body than in the lower body, because of normal cardiac output with severe impairment of pulmonary function. Hereby, we report the diagnosis and the treatment of differential hypoxia caused by veno-arterial ECMO. A 39-year-old man received cardiopulmonary resuscitation from a cardiac arrest due to acute myocardial infarction. Even after more than 30 min of resuscitation, spontaneous circulation had not resumed. Next, we performed veno-arterial ECMO through the femoral artery and vein, and the patient recovered consciousness on the second day of ECMO. On day 5 of ECMO, he lost consciousness again and presented a generalized tonic-clonic seizure, and an electroencephalogram showed delta waves suggesting diffuse cerebral cortical dysfunction. While an echocardiogram revealed improvements in myocardial function, a follow up chest radiograph showed increasing massive parenchymal infiltrations, and gas analysis of blood from the right radial artery revealed severe hypoxemia. These findings indicated a definite diagnosis of differential hypoxia, and therefore, we inserted a 17-Fr cannula into the left subclavian vein as a return cannula. The patient's consciousness and pulmonary infiltrations were improved 2 days after veno-arterial-venous ECMO, and the electroencephalogram showed normal findings. To our knowledge, this is the first report of successful clinical management of differential hypoxia. We suggest that veno-arterial-venous ECMO could be the treatment of choice for differential hypoxia resulting from veno-arterial ECMO.

Keywords: Brain; Extracorporeal membrane oxygenation; Lungs; Pulmonary function.

Figure 1

Images showing clinical progression of differential hypoxia. Electrocardiogram shows depressions of the ST segment in V1 to V6 leads (A). Coronary angiography reveals a simple lesion in the left circumflex coronary artery (B). Severe pulmonary edema and bilateral pleural effusions are observed on the chest radiograph (C). Pulmonary edema was improved after veno-arterial venous extracorporeal membrane oxygenation (D).

Figure 2

Conversion of electroencephalogram. At the time of admission electroencephalogram showed generalized reactive theta slowing (A). On the fifth day of extracorporeal membrane oxygenation support, generalized delta activity with superimposed beta frequency was evident (B). The electroencephalogram returned to normal configurations after veno-arterial venous extracorporeal membrane oxygenation (C).

Figure 3

Schematic diagrams of circulation during extracorporeal membrane oxygenation (ECMO). The diagrams indicate circulation in the case of typical veno-arterial ECMO (A), differential hypoxia (B), and veno-arterial venous ECMO (C). Red or pink arrows = oxygenated blood; blue arrows = deoxygenated blood; downward arrows = cardiac output; upward arrows = retrograde ECMO output.