ECHOCARDIOGRAPHIC
MONITORING ON ECMO
M.Mondino MD
Dept.of Cardiac Anesthesia and CV-ICU
Niguarda Hospital, Milan
Extra-Corporeal Membrane Oxygenation
ECMO is a rescue therapy used to provide cardiac
and/or respiratory support for critically ill patients in
whom maximal conventional medical management has
failed.
V-V ECMO: provides adequate oxygenation and
carbon dioxide removal in isolated refractory
respiratory failure.
V-A ECMO: when support is required for cardiac and/or
respiratory failure.
ECHOCARDIOGRAPHIC
MONITORING ON ECMO
•
•
•
•
•
Patient selection
Insertion and correct placement of
cannulas
Monitoring during support
Detecting complications
Decision making: cardiac recovery, weaning, bridge
to..
ECHOCARDIOGRAPHIC
MONITORING ON ECMO
• Patient selection
•
•
•
•
Insertion and correct placement of
cannulas
Monitoring during support
Detecting complications
Decision making: cardiac recovery, weaning, bridge
to..
Pt selection
- Reversible causes of hemodynamic instability
V-A ECMO controindications
Aortic dissection
Aortic valve regurgitation
Absoulte
controindications
Severe Arterial vascular
disease
central vs peripheral
surgical vs percutaneous
4
Pt selection
V-V ECMO controindications
Severe Pulmonary
Hypertension
Cardiac Failure
Consider VAECMO
Pt selection
Right Heart anomalies
• atrial septal defect
• interatrial septal aneurysm
• patent foramen ovale
• prominent Chiari network
• pacemaker or ICD leads
Pt selection
Chiari’s network
Chiari’s network: review of the literature, Marios Loukas et al., Surg Radiol Anat (2010) 32:895
901
Pt selection
Interatrial septal aneurysm
The Internet Journal of Cardiology ISSN: 1528-834,”Isolated large atrial septal aneurysm and multiple cerebral infarcts:
Is there any association?” Gerasimos Gavrielatos et al.
Pt selection
Atrial septal defect (ASD) Patent foramen ovale (PFO)
ECHOCARDIOGRAPHIC
MONITORING ON ECMO
• Patient selection
•
•
•
•
Insertion and correct placement of cannulas
Monitoring during support
Detecting complications
Decision making: cardiac recovery, weaning, bridge
to..
Insertion and correct placement of
cannulas
Echocardography can visualize the correct position of
both wires and cannula.
Insertion and correct placement of
cannulas
3d Echo
Insertion and correct placement of
cannulas
Peripheral VA ECMO
The venous cannula should be positioned in the mid right
atrium to allow optimal blood flow into the circuit.
The peripheral arterial cannula cannot be visualized.
Imaging of the guide-wire in the ascending Ao can
prevent malpositioning of the cannula.
Insertion and correct placement of
cannulas
VA ECMO
Insertion and correct placement of
cannulas
cVA-ECMO
Insertion and correct placement of
cannulas
V-V ECMO
The
return
cannula
should be in the
mid right atrium.
The
access
cannula tip should
be in the proximal
IVC.
Insertion and correct placement of
cannulas
V-V ECMO
Echo is essential to check position of the cannulas in
relation to IAS, PFO, LA, TV, CS etc.
Incorrect cannula position can lead to:
-Ricirculation
-Inadequate blood flow
-Myocardial injury
Insertion and correct placement of
cannulas
Avalon cannula
It consists of 2 lumens:
-one lumen allows the deoxygenated
blood to drain from the IVC and the
SVC
-the second lumen allows the
oxygenated
blood to return directed toward the
tricuspid valve.
-reduces the recirculation seen with the
traditional V-V setup
ECHOCARDIOGRAPHIC
MONITORING ON ECMO
• Patient selection
•
•
•
•
Insertion and correct placement of
cannulas
Monitoring during support
Detecting complications
Decision making: cardiac recovery, weaning, bridge
to..
Monitoring of the Pt on pVA-ECMO
•
•
Underlying LV
dysfunction
Increased afterload due to
retrograde VA Ecmo flow
Insuffiencent unloading of LV
• Pulmonary congestion, oedema, hemorrhage.
• Blood stagnation in LV
• Myocardial injury (affecting recovery)
Monitoring of the Pt on pVA-ECMO
Adequate LV unloading
AHF in DCMP, pVA ECMO (3 days) + Inotropes + IABP. WP=13, RAP= 8 mmHg
Echo Monitoring:
Reg.
- Myocardial contractility
- LVEDV
- Aortic Valve opening and Mitral Valve
Monitoring of the Pt on VA-ECMO
Adequate LV unloading
15 yrs. male. Acute myocarditis, pVA-Ecmo (day1) + IABP +
Inotropes
Monitoring of the Pt on VA-ECMO
Adequate LV unloading is vital
• Inotrops and vasodilators
• IABP
• Atrioseptostomie
• LV vent
•
Anterograde and Retrograde LV unloading
Monitoring of the Pt on VA-ECMO
Adequate LV unloading
Catena et al.,”Role of Echocardiography in the perioperative managment of
mechanical circulatory support”. Best practice & Reserach Clinical
Anaesthesiology 26 (2012)
Monitoring of the Pt on VA-ECMO
Adequate LV unloading
Female, 2 ys;
Fulminant myocarditis
cVA ECMO (30 days)
Bridged to recovery
Monitoring of the Pt on VA-ECMO
Adequate Venous Pressure unloading
Female, 43 ys
Liver
congestion
in
acute
cardiac
decompensation
of
HCMP
Monitoring of the Pt on VA-ECMO
Adequate Venous Pressure unloading
Hepatic vein flow
Before pVA ECMO
During pVA ECMO
Monitoring of the Pt on V-V ECMO
Increases mixed SvO2
Decreases PVR
Decreases RV afterload
Increases coronaries
O2 content
Increases LVEF
ECHOCARDIOGRAPHIC
MONITORING ON ECMO
• Patient selection
•
•
•
•
Insertion and correct placement of
cannulas
Monitoring during support
Detecting complications
Decision making: cardiac recovery, weaning, bridge
to..
ECMO Complications
Anticoagulation
Bleeding
Cannulas
Thrombosis Displacement Flow
Obstruction
ECMO Complications - Thrombosis
Intraventricular thrombosis is a well know complication
of
myocardial infraction. pECMO and LV akinesis can
increase
this risk.
31
ECMO Complications - Thrombosis
“The Role of Echocardiography and Other Imaging Modalities in Patients With Left Ventricular Assist
Devices”. Jerry D. J Am Coll Cardiol Img. 2010;3(10):1049-1064.
ECMO Complications – Venous Flow
obstruction
Obstruction of the IVC:
- Liver and splanchnic organs congestion
Obstruction of the SVC:
- SVC syndrome and reduced cerebral
perfusion
ECMO Complications - Flow obstruction
Obstruction of the IVC
Venous Flow obstruction
ECMO Complications - Bleeding
Tamponade
Pericardial effusion might became evident when Ecmo
support is reduced.
ECMO Complications
Cannula malposition
• Interatrial septum
• Coronary sinus
• Across the tricuspid valve
• Through a patent foramen ovale and into the
LV
ECMO Complications - Cannula malposition
Atrial septal aneurysm occluding the inflow cannula.
Augoustides J et al.. J Cardiothorac Vasc Anesth 17:113-120, 2003
ECHOCARDIOGRAPHIC
MONITORING ON ECMO
• Patient selection
•
•
•
•
Insertion and correct placement of
cannulas
Monitoring during support
Detecting complications
Decision making: cardiac recovery, weaning, bridge
to..
Weaning and Recovery
IF and WHEN
BTR, BTB, BTVAD, BTTx, BT?
There are no established weaning guidelines
clinical
judgment
hemo
Echo
dynamic
variables
parameter
s
Weaning and Recovery
Echocardiographic parameters of possible recovery
• LVEF > 35-40%
• LVED diameter < 55mm
• Aortic velocity-time integral >10 cm
• Aortic Valve opening pattern
• Absence of LV dilatation
Weaning and Recovery
Decreasing VA-ECMO support determines a
reduction in LV afterload and increase in LV
preload.
Conventional echo recovery parameters are
dependent on loading conditions.
The systolic velocities (TDI-Sa) of the mitral annulus
measured by Doppler tissue imaging were found to be
load independent and to have significant prognostic value
for predicting ECLS weaning.
Aissaoui N.et al, JASE,Vol. 25, Issue 6, June 2012.
michelegiovanni.mondino@ospedaleniguarda.it
Thank You
Niguarda Hospital 1950