Introduction: Refractory pulmonary arterial hypertension and RV (right ventricular) dysfunction can be a life-threatening and challenging complication in the ICU. VA (veno-arterial) ECMO (extracorporeal membrane oxygenation) can provide indirect RV support but can potentially increase LV (left ventricular) afterload and limit RV decompression. VP (veno-pulmonary) ECMO directly supports the RV, resulting in hemodynamic optimization and RV rest, increasing the potential for recovery. Description: A 36-year-old female with pulmonary arterial hypertension (PAH) and autoimmune hepatitis underwent liver transplantation and was progressing well until postoperative day (POD) 4, when she was noted to have an increasing oxygen demand, decreased urine output and dilated RV. Despite continuous renal replacement therapy, inotropic support and inhaled vasodilator, she continued to decompensate until POD 6 she was cannulated for veno-arterial (VA) ECMO. Although she initially had improved markers of perfusion and decreased inotropic support requirements, she then began to require escalation of inotropes and worsening RV dilation. While on higher inotropic doses and further fluid removal, on POD 12 she failed a VA ECMO weaning trial. On POD 15 she was cannulated for VP ECMO using a ProtekDuo cannula in parallel with VA ECMO. This strategy led to immediate hemodynamic improvement, reduced RV dilation, and allowed decannulation from VA ECMO after 2 days. VP ECMO was weaned off and she was decannulated by POD 21. She was discharged home on post-op day 47. Discussion: This patient had PAH and RV failure refractory to aggressive fluid removal, inotropes, pulmonary vasodilators and VA ECMO. The addition of direct RV support with VP ECMO enabled targeted RV support and rest, delivery of oxygenated blood to the pulmonary artery, likely improvement in pulmonary vascular resistance and weaning of VA ECMO support. Further research is needed to assess escalation and combined approaches in mechanical circulatory support for refractory PAH and RV failure.
Perkins et al. (Sun,) studied this question.