894 Letters to the Editor / European Journal of Cardio-Thoracic Surgery before right ventricular and clinical deterioration, either surgically or by any Christian Napp has received lecture honoraria from Maquet. Jan D. Schmitto other upraising percutaneous technique’. is a Consultant/Advisor for HeartWare, Thoratec and ReliantHeart. Also, surgery is no longer the devil it used to be! REFERENCES REFERENCES  Angleitner P, Roggla M, Laufer G, Wiedemann D. Watershed of veno-  Redondo A, Lopez-Menendez J, Miguelena J, Varel L. When not to perform arterial extracorporeal life support. Eur J Cardiothorac Surg 2016;50:785. isolated tricuspid valve surgery? Our long-term experience in tricuspid  Napp LC, Brehm M, Kuhn C, Schafer A, Bauersachs J. Heart against veno- valve replacement in highly symptomatic patients. Eur J Cardiothorac Surg arterial ECMO: competition visualized. Int J Cardiol 2015;187:164–5. 2018;53:893.  Kato J, Seo T, Ando H, Takagi H, Ito T. Coronary arterial perfusion during  Antunes MJ, Rodr ıguez-Palomares J, Prendergast B, De Bonis M, Rosenhek venoarterial extracorporeal membrane oxygenation. J Thorac Cardiovasc R, Al-Attar N et al. Management of tricuspid valve regurgitation. Eur J Surg 1996;111:630–6. Cardiothorac Surg 2017; 52:1022–30.  Napp LC, Kuhn C, Hoeper MM, Vogel-Claussen J, Haverich A, Schafer A et al. Cannulation strategies for percutaneous extracorporeal membrane oxygenation in adults. Clin Res Cardiol 2016;105:283–96. *Corresponding author. Centro de Cirurgia Cardiotor acica, Hospitais da  Napp LC, Tongers J, Schmitto JD, Schafer A. Venoarterial extracorporeal Universidade, 3000-075 Coimbra, Portugal. Tel: +351-239-400418; membrane oxygenation: lower speed, and you may be faster. Ann Thorac fax: +351-239-829674; e-mail: firstname.lastname@example.org (M.J. Antunes). Surg 2017;104:724–5. doi:10.1093/ejcts/ezx446 Advance Access publication 12 December 2017 * Corresponding author. Klinik fu ¨ r Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany. Tel: +49-511-5322246; fax +49-511-5325412; e-mail: napp.christian@mh-han nover.de (L.C. Napp). doi:10.1093/ejcts/ezx375 The short- and long-term risks of Advance Access publication 6 November 2017 venoarterial extracorporeal membrane oxygenation watershed a, b a a L. Christian Napp *, Jan D. Schmitto ,Jo¨rn Tongers and Andreas Sch€ afer Reply to Napp et al. Department of Cardiology and Angiology, Cardiac Arrest Center, Hannover Medical School, Hannover, Germany a, b a Philipp Angleitner *, Martin Ro¨ggla ,Gu¨nther Laufer and Department of Cardiothoracic, Transplantation and Vascular Surgery, Dominik Wiedemann Hannover Medical School, Hannover, Germany Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria Department of Emergency Medicine, Medical University of Vienna, Vienna, Received 26 August 2017; accepted 30 September 2017 Austria Keywords: Extracorporeal membrane oxygenation � Watershed � Cardiogenic Received 28 September 2017; accepted 30 September 2017 shock � Myocardial recovery � Oxygenation Keywords: Extracorporeal membrane oxygenation � Watershed � Cardiogenic We thank Angleitner et al.  for their interesting image. It prototypically illus- shock � Myocardial recovery � Oxygenation trates the watershed, a phenomenon that inevitably occurs during venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support with femoral We thank Napp et al. [1, 2] for their valuable comments. We agree with every cannulation. The resulting changes in blood pressure, ﬂow and oxygenation point raised by the authors. Increasing extracorporeal life support (ECLS) are complex. In this context, we consider the present image as being import- speed and thereby left ventricular (LV) afterload might impair myocardial re- ant and highly educative for the reader. covery; therefore, ECLS speed is usually set as low as possible but as high as Notwithstanding, we feel that the notion ‘the increase of ECLS ﬂow resulted in necessary. To clarify our therapeutic strategy in this case, we will give a short improved upper body oxygenation’ requires further comment. It is true that description of our management. oxygenation of blood originating from the left ventricle may be low in the pres- The patient underwent out-of-hospital cardiopulmonary resuscitation for ence of lung failure, which might pose a risk to the upper body and especially cardiogenic shock in ventricular ﬁbrillation. After a total of 90-min ongoing the brain. Further, it is true that the watershed position is a function of the com- cardiopulmonary resuscitation, there was still no return of spontaneous circu- petition between antegrade left ventricular output and retrograde ECMO output lation. Therefore, we performed ECLS implantation via femoral cannulation.  (beyond other factors). As such, an increase in ECMO output might shift the After initiation of ECLS ﬂow (at 3 l/min), further diagnostic testing was per- watershed to a more proximal position in many patients, which potentially im- formed including computed tomography and cardiac catheterization. proves brain oxygenation. However, an increase in ECMO output leads to a Transthoracic echocardiography revealed a hypertrophic myocardium with strong increase in left ventricular afterload, reduces transpulmonary blood ﬂow severely impaired LV function, leading to the working diagnosis of hyper- and very likely impairs coronary oxygenation . These changes counteract trophic cardiomyopathy as underlying disease. At this point, the arterial blood myocardial recovery and should be avoided. Thus, from a myocardial perspec- pressure line was pulsatile, conﬁrming that antegrade left ventricular ejection tive, other strategies such as optimized ventilation, improved medical manage- was not suppressed by retrograde aortic ECLS ﬂow. However, poor upper ment, escalation to veno-arterio-venous-ECMO  or active left ventricular body saturation was apparent, as demonstrated in our image . To assure ad- unloading should be evaluated instead of just increasing ECMO speed with the equate brain saturation, we decided to increase ECLS ﬂow to 4 l/min to imme- intention to shift the watershed. Overall, although full ECMO speed may be diately stabilize the patient. required in selected patients, the majority probably beneﬁt from a careful reduc- In situations like this, it is very important to do an intensive workup of tion of ECMO ﬂow  adapted to individual needs. the patient to make a highly individualized decision. In case of an absolutely non-contracting left ventricle not capable of ejecting against ECLS ﬂow despite Conﬂict of interest: L. Christian Napp, Jo ¨ rn Tongers and Andreas Sch€ afer increased inotropic support, we recommend unloading the left ventricle. have received travelling support and lecture honoraria from Abiomed, Unloading strategies include implantation of a permanent LV assist device, Andreas Sch€ afer is supported by a research grant from Abiomed and L. Impella implantation, direct LV venting and connection to the venous ECLS Downloaded from https://academic.oup.com/ejcts/article-abstract/53/4/894/4596630 by Ed 'DeepDyve' Gillespie user on 16 March 2018
European Journal of Cardio-Thoracic Surgery – Oxford University Press
Published: Apr 1, 2018
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