Venovenous extracorporeal membrane oxygenation in obese patients

Javidfar, J., Zaaqoq, A. M., Yamashita, M. H., Eschun, G., Jacobs, J. P., Heinsar, S., Hayanga, J. W., Peek, G. J., & Arora, R. C. JTCVS techniques DOI 10.1016/j.xjtc.2021.08.048

Central Message: Venovenous ECMO in obese patients poses unique challenges that may be mitigated through planning and precise execution. Prone positioning, use of esophageal balloons, and a thoughtful ventilator strategy might obviate need for ECMO.

Feature Editor's Note—The use of venovenous (VV) extracorporeal membrane oxygenation (ECMO) has experienced broader adoption over the preceding decade for the management of respiratory failure. As experience with VV-ECMO has grown, VV-ECMO has been applied to more patients afflicted with a greater burden of comorbidities, which has been particularly evident during the global COVID-19 pandemic. One of the more common comorbidities is that of obesity. The use of VV ECMO in obese patients poses significant challenges and requires adoption of different techniques to achieve adequate respiratory support and successful outcomes. In this Invited Expert Technique article, Javidfar and colleagues review respiratory management and VV-ECMO techniques for application in obese patients. The authors discuss optimal respiratory management practices including use of esophageal pressure monitoring to assess lung pressures and special considerations in use of prone positioning. Optimal cannulation techniques are reviewed as well as techniques to obtain optimal ECMO flow, gas exchange and oxygenation, and facilitate airway management and physical therapy. Importantly, the authors review thresholds and situations in which conversion to veno-arterial ECMO might be necessary. Javidar and colleagues should be congratulated on a timely, insightful, and comprehensive review on the topic VV-ECMO for respiratory failure in obese patients and for providing an excellent guide to achieving optimal outcomes.