Table 2

Protocol for Bicaval dual lumen Avalon cannula placement under transthoracic echocardiography guidance

StepHow to do
1Place an X-ray cassette underneath the patient’s back. Insert the guidewire through the IJV puncture until observing the guidewire in subcostal bicaval view.
2Re-examine and exclude RV looping with subcostal bicaval view (guidewire bending towards the tricuspid or aortic valve), subcostal four-chamber view (guidewire in the RV inlet and RV sinus), subcostal short-axis view (guidewire in the right ventricular outflow tract), and if possible: parasternal RV inflow and other parasternal and apical views.
3Estimate the distance from the IJV puncture to the xiphoid processus. After multiple dilatation, advance the Avalon cannula cautiously with continuous ECG monitoring and real-time subcostal bicaval view observation. When the cannula is about to attain the right atrium, exchange alternatively between the subcostal bicaval view and subcostal four-chamber view for early detection of malposition cannula into the RV. This step is successful when observing the distal part of the cannula in the IVC.
4Initiate the ECMO circuit. Use the subcostal four-chamber view, modifying and focusing on the right atrium. Adjust colour gain and Nyquist limit to best obtain the jet emanating from the infusing port. Rotate the cannula to make the returning blood flow towards the tricuspid valve. Fix the cannula to avoid rotational dislocation.
5Perform bedside chest radiograph (with the previously placed X-ray cassette) to make a standard landmark for cannulation.
6Re-examine the cannula position by ultrasound and X-ray daily and whenever suspected any abnormality with ECMO circuit.
  • ECMO, extracorporeal membrane oxygenation; IJV, internal jugular vein; RV, right ventricular.