ECHOCARDIOGRAPHIC MONITORING ON ECMO

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ECHOCARDIOGRAPHIC MONITORING ON ECMO
M.Mondino MD Dept.of Cardiac Anesthesia and
CV-ICU Niguarda Hospital, Milan
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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.
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ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Patient selection

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications

• Decision making cardiac recovery, weaning,
  bridge to..

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ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Patient selection

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications

• Decision making cardiac recovery, weaning,
  bridge to..

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Pt selection
V-V ECMO controindications Severe
Pulmonary Hypertension Cardiac Failure
Consider VA-ECMO
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Pt selection
Right Heart anomalies

• atrial septal defect
• interatrial septal aneurysm
• patent foramen ovale
• prominent Chiari network
• pacemaker or ICD leads

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Pt selection
Chiaris network
Chiaris network review of the literature,
Marios Loukas et al., Surg Radiol Anat (2010)
32895901
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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.
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Pt selection
Atrial septal defect (ASD) Patent foramen ovale
(PFO)
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ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Patient selection

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications

• Decision making cardiac recovery, weaning,
  bridge to..

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Insertion and correct placement of cannulas
Echocardography can visualize the correct
position of both wires and cannula.
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Insertion and correct placement of cannulas
3d Echo
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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.
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Insertion and correct placement of cannulas
VA ECMO
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Insertion and correct placement of cannulas
cVA-ECMO
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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.
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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
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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
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ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Patient selection

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications

• Decision making cardiac recovery, weaning,
  bridge to..

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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)

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Monitoring of the Pt on pVA-ECMO
Adequate LV unloading
AHF in DCMP, pVA ECMO (3 days) Inotropes
IABP. WP13, RAP 8 mmHg
Echo Monitoring - Myocardial
contractility - LVEDV -
Aortic Valve opening and Mitral Valve Reg.
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Monitoring of the Pt on VA-ECMO
Adequate LV unloading
15 yrs. male. Acute myocarditis, pVA-Ecmo (day1)
IABP Inotropes
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Monitoring of the Pt on VA-ECMO
Adequate LV unloading is vital

• Inotrops and vasodilators
• IABP
• Atrioseptostomie
• LV vent
• Anterograde and Retrograde LV unloading

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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)
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Monitoring of the Pt on VA-ECMO
Adequate LV unloading
Female, 2 ys Fulminant myocarditis cVA ECMO (30
days) Bridged to recovery

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Monitoring of the Pt on VA-ECMO
Adequate Venous Pressure unloading
Female, 43 ys Liver congestion in acute cardiac
decompensation of HCMP
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Monitoring of the Pt on VA-ECMO
Adequate Venous Pressure unloading
Hepatic vein flow
Before pVA ECMO
During pVA ECMO
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Monitoring of the Pt on V-V ECMO
Increases mixed SvO2
Increases coronaries O2 content
Decreases PVR
Decreases RV afterload
Increases LVEF
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ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Patient selection

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications

• Decision making cardiac recovery, weaning,
  bridge to..

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ECMO Complications
Anticoagulation
Cannulas
Bleeding
Thrombosis
Displacement
Flow Obstruction
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ECMO Complications - Thrombosis
Intraventricular thrombosis is a well know
complication of myocardial infraction. pECMO and
LV akinesis can increase this risk.
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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.
20103(10)1049-1064.
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ECMO Complications Venous Flow obstruction
Obstruction of the IVC - Liver and splanchnic
organs congestion
Obstruction of the SVC - SVC syndrome and
reduced cerebral perfusion
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ECMO Complications - Flow obstruction
Obstruction of the IVC
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Venous Flow obstruction
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ECMO Complications - Bleeding
Tamponade
Pericardial effusion might became evident when
Ecmo support is reduced.
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ECMO Complications Cannula malposition

• Interatrial septum
• Coronary sinus
• Across the tricuspid valve
• Through a patent foramen ovale and into the LV

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ECMO Complications - Cannula malposition
Atrial septal aneurysm occluding the inflow
cannula.
Augoustides J et al.. J Cardiothorac Vasc Anesth
17113-120, 2003
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ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Patient selection

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications

• Decision making cardiac recovery, weaning,
  bridge to..

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Weaning and Recovery
IF and WHEN
BTR, BTB, BTVAD, BTTx, BT?
There are no established weaning guidelines
clinical judgment
Echo variables
hemo dynamic parameters
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Weaning and Recovery
Echocardiographic parameters of possible recovery

• LVEF gt 35-40
• LVED diameter lt 55mm
• Aortic velocity-time integral gt10 cm
• Aortic Valve opening pattern
• Absence of LV dilatation

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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.
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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.
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michelegiovanni.mondino_at_ospedaleniguarda.it Thank
You
Niguarda Hospital 1950