Veno-veno-arterial ECMO support for acute myocarditis combined with ARDS: a case report

In patients who developed a combined situation of severe acute respiratory distress syndrome with refractory hypoxemia and acute cardiac failure with circulatory collapse, traditional veno-venous or veno-arterial extracorporeal membrane oxygenation approach alone may not be sufficient enough to maintain both an acceptable range of gas exchange and a hemodynamic stability.

A 27-year-old male patient was suffering from severe acute respiratory distress syndrome caused by community-acquired pneumonia and acute myocarditis with circulatory shock. After mechanical ventilation for respiratory support, he was in a persistently refractory shock state. Veno-veno-arterial mode of extracorporeal membrane oxygenation was thus applied to provide both respiratory and circulatory support simultaneously, with good success.

Modifying to a veno-veno-arterial mode can be another alternative strategy in a combined situation of refractory respiratory and cardiac failure, thus providing not only respiratory support but also circulatory support. In veno-veno-arterial mode, the returning circuit from the pump was divided with a Y connector into 2 reinfusion circuits; each reinfusion circuit was connected to the contralateral side femoral vein and artery, respectively. The distribution of reinfusion flow was adjusted depending on the patient's cardiopulmonary status.

Although there is no consensus about the veno-veno-arterial mode of extracorporeal membrane oxygenation, this combined mode can be helpful in patients with acute refractory respiratory and cardiac failure, as shown in the present case. We need further experience and improvements in the circuit system used in the veno-veno-arterial mode of ECMO.