Problem based learning Discussion

Dr Priya R Menon
Herzzentrum Leipzig
Germany
Role of TEE in ECMO

Plays a fundamental role throughout the entire journey of a patient supported on

ECMO.

• Assists in patient selection

• Guides the insertion and placement of cannulas

• Monitors progress

• Detects complications

• Evaluates cardiac recovery and the weaning of ECMO support.

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CASE

• A 56-year-old female, 65 kg, underwent emergency CABG for a spontaneous

dissection of her LMCA causing cardiogenic shock. She required bolus doses of
epinephrine and intermittent chest compressions from the time of hospital
admission until institution of CPB, She had grafts placed to her LAD and
Cx.Currently, she is unable to wean from CPB due to left ventricular failure
despite resting on CPB, IABP, and high dose inotropic support.

• What Are the Options for Mechanical Cardiovascular Support?

• .

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• The two options are a short-term left ventricular assist device (LVAD) and veno-
arterial (VA) ECMO

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VA ECMO is Chosen, What Are the Options for Cannulation

• Return to the ascending aorta, drainage from the right atrium-Central

• Return to the femoral artery, drainage from the inferior vena cava or right atrium
via a cannula inserted in the femoral vein-Peripheral

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VA ECMO
Provides both cardiac and resp support

INFLOW Cannula – RA

ECMO – Oxygenator

OUTFLOW Cannula – Aorta asc./

Rt subclavia art./ Femoral art

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 Role of ECHOs in ECMO

• Pre-Implantation
- Look for:
 Aorticdissection

 Aortic valve insufficiency (esp VA-ECMO)

- R/O Difficult placement

 Atherosclerosis

 PFO / ASD

 Chiari-Network

 PM/Defibrillator wires 7
 Role of ECHO in ECMO
ME bicaval view

copyright ©2010-2015 University Health Network Anesth Analg 1999;12:884-900 8

 Role of ECHO in ECMO
Vena cava inferior

copyright ©2010-2015 University Health Network Anesth Analg 1999;12:884-900 9

 Role of ECHO in ECMO

• Cannulation

- Venous Cannula:

 RA

 Superior Vena Cava

 Inferior Vena Cava

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Role of ECHO in ECMO

• Cannulation
- Arterial Cannula
 Femoralis Artery

 Axillary Artery

 Ascending Aorta

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• The patient is placed on peripheral VA ECMO. Inotropic support and IABP are
discontinued. Blood flow is 4 L/min, pump speed is 3500 rpm, MAP is 65
mmHg, HR 40 beats/min, SaO2 is 98%, and the oxygen saturation in the
drainage cannula (SDO2) is 65%. 30 minutes after initiating VA ECMO the
patient develops frothing pulmonary edema

• What Next?

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TEE

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Role of ECHO in ECMO

• With LV-Dysfunction→
- LVEDP/ LVEDV:
 LV-Distension

 Mitralvalve regurgitation

 AV doesnt open with each beat

» No IBP curve on the Monitor

» Stagnation of blood in Ascending Aorta, LV

and Pulmonary veins

) Limitied Indication if severly LV-failure

The Combination of ECMO and IABP betters the Function and Myocardial perfusion of
LV (only if Central cannulation)
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Failure of AV to open during Peripheral VA Ecmo

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Cause

• In non-ejecting or minimally ejecting left ventricles blood from bronchial,

thebesian veins and right sided circulation will gradually increase left atrial
pressure leading to pulmonary edema.Even the arterial cannula can cause
increase in afterload and leading to increase in LVEDP and thus LAP.

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What Can Be Done to Improve the Situation?

• A modest reduction in LAP was obtained by increasing ECMO circuit flow (to
reduce pulmonary blood flow)

• Restarted inotropic support (to facilitate left ventricular ejection).

• Urgent decompression of the left heart via an atrial septostomy (which may be
performed surgically or percutaneously) or LV vent insertion

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Feasible more in kids

How does it help?

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• Shifted to ICU

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Patient shifted to ICU------After 8 hours

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• Complication
 Chamber-Distension

 Chamber-Compression

 Worsening of ventricular Function

 Worsening of ECMO-Flow

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Role of ECHO in ECMO

- Main causes
 Thrombosis

 Dislocation of Cannula

 Tamponade

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Pericardial tamponade

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After 24 hours

• Low flow alarm and suddenly there is no ECMO

output

• OMG

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• Pump head is half full with air bubbles.

• Massive air bubble from venous due to disconnection of a vent attached to the
venous cannula.

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 AIR EMBOLISM
• Introduction of air into circuit through connections or cannulation sites

• Massive embolus into the pump head will de-prime the pump with loss of ECMO
support

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Management

Clamp arterial return line Start CPR and/or manual bag oxygenation

• The arterial air emboli are likely to travel to the uppermost parts of the patient; thus, the brain and upper
limbs are most at risk.

• Stop pump Put patient head down and Increase ventilation inotropes and Volume As embolus entered
patient arterial system (VA) so induce hypothermia’ and adminster barbiturates, steroids, mannitol
(neuroprotective)

• Circuit Management

• Clamp circuit , Turn off pump

• Ensure pump head outlet is at 12 o’clock position

• Examine site for air & seal if possible an further management requires perfusionist

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Weaning from ECMO

• Pre weaning-

• Patient meets the criteria of being afebrile and euvolemic

• Resolution of pulmonary edema on x-ray film

• Adequate upper extremity arterial Pao2 and all pre-ECMO end-organ dysfunction
recovered to baseline.

• Weaning trial, anticoagulation titrated to a Aptt target of 60 to 70 seconds to

avoid thrombotic complications while decreasing ECMO flow over the period of
assessment.

• Swan-Ganz catheter insertion during the weaning process??

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Why TEE has been used as a gold standard for cardiac monitoring during
weaning

• No other technology exists that can be used at the bedside by the cardiac intensivist for any duration of
time and at any time of day for accurate monitoring of the ECMO patient

• Swan-Ganz catheter via traditional thermodilution is of limited value in patients on ECMO

• Minimally invasive measurement of cardiac output via pulse contour, esophageal Doppler, partial
carbon dioxide rebreathing, and thoracic bioimpedance of the thoracic aorta is similarly not reliable in the
setting of VA ECMO.

• Serial MvO2 assessments require a Swan-Ganz catheter, and there are always time gaps between
samplings, which do not reflect real-time dynamic changes of the ventricle.

• Arterial waveform analyses may be helpful to determine the ejection of the heart; but it does not directly
reflect cardiac volume status.

• ..

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Role of Echo in weaning

• Cardiac recovery is often marked by increasing pulsatility seen on the patient’s

arterial line tracing

Echo Parameters for that may suggest an attempt to cease ECMO support

• LV ejection fraction > 35% to 40%

• LV outflow tract velocity-time integral > 10 cm

• Absence of LV dilatation, and no cardiac tamponade

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 ECMO-Weaning-Plan
(in 0,25l / 4 Stunden Schritten, maximal 1,5l / Tag )
Zeit Fluss MAD MPAD Diurese Lactat SvO2 Wedge ZVD eFiO2
Tage

1. 08:00
Tag
12:00

16:00

20:00

24:00

04:00

2. 08:00
Tag
12:00

16:00

20:00

24:00

04:00

3. 08:00
Tag
12:00

16:00

20:00

24:00

04:00

08:00

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VA ECMO flows were reduced 0.25 L/4hr increments and the clinical and
hemodynamic parameters ( HR, BP, arterial waveform pulsatility, PaO2 level in a
right radial arterial line, and changes in CVP and PAP) and echo parameters
(stroke volume, ventricular dimensions, ventricular volumes, and ejection fraction)
were assessed.

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Weaning Problems

• Circuit flows ≤1.5L/min and oxygenation is being achieved using the ventilator
exclusively.

• There is drop in saturations and PaO2 in ABG is 90 on a FiO2 of 1

• What next

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• In this situation the circuit flow acts as a right-to-left shunt. If adequate
oxygenation and CO2 removal can be maintained in the presence of this shunt it
is likely that respiratory failure can be managed without ECMO.

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ECMO Monitoring

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Thanks

ME bicaval view ME Rt vnt inflow outflow view

Inferior Vena cava view 4-Chamber

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