This workshop will outline the basic principles of extracorporeal life support made easy by key-experts in the field. During the course delegates will gain a good understanding of ECMO in the following areas: Theoretical concepts, basic physiology and pathophysiology, cardiac and respiratory support and monitoring, alarm settings and monitoring, role of cardiac ultrasound during ECMO, newest technologies, circuits and devices, practical hands-on sessions and simulations.

1. Echocardiography and ECMO
Stijn Lochy
UZ Brussel
Interventional cardiology
Intensive Care

2. Echocardiography and ECMO
 Echo(cardio)graphy is the side-kick of ECMO
 Its use is of key importance during:
− Assesment of ECMO indications and contra-indication
− Cannulation and guidance of ECMO initiation
− Follow-up, monitoring and detecting complications during ECMO
− Weaning from ECMO

3. Assesment of ECMO indications and contra-
indications
 Do a comprehensive echocardiographic evaluation before the start of
ECMO

4. Assesment of ECMO indications and contra-
indications
 Even in situations of severe hemodynamic compromise (E-CPR), go
for a focused and goal-oriented echocardiography
− Refractory cardiac arrest because of tamponade does not need to be treated
with ECMO
 Choice between respiratory and cardiac ECMO is not always easy -
echo can help
− Up tot 35% with ARDS have severe RV dysfunction; VV ECMO will often resolve
the problem, but sometimes switch to VA(V) ECMO is needed

5. Assesment of ECMO indications and contra-
indications
 Prognostication and treatment plan
− Pre-existing RV dysfunction is a predictor of outcome in patients treated with
ECMO after cardiac surgery
− Cardiogenic shock after myocardial infarction is not always due to severe LV
dysfunction; look for mechanical complications
 Contra-indications
− Look for aortic dissection and aortic regurgitation

6. Cannulation and guidance of ECMO
initiation
 Ultrasound is beneficial in gaining vascular access
 Identification of severe atheromatous disease with artery stenosis at
access site
 Combined echocardiography and fluoroscopy is in our point of view
ideal for guidewire and canulla placement
 For specific situations (Avalon dual lumen cannula), combining TEE
and TTE can be beneficial

7. Cannulation and guidance of ECMO
initiation
 Subcostal (TTE) and bicaval (TEE) views are the most important views
for procedure guidance and cannula positioning
 In femoral VV ECMO, the tip of a femoral drainage cannula should be
placed at IVC/RA junction
 Placement of a drainage cannula too deep in RA, might lead to
damage to cardiac structures, and to problems of recirculation

8. Cannulation and guidance of ECMO
initiation
 Extra attention is needed when implanting a Avalon Elite dual lumen
cannula, avoiding cannulation of a hepatic vein
 Pay attention that the tip of the cannula, cannot clearly be identified
with the guidewire in place

9. Cannulation and guidance of ECMO
initiation

10. Cannulation and guidance of ECMO
initiation

11. Cannulation and guidance of ECMO
initiation

12. Follow-up, monitoring and detecting
complications during ECMO
 Ideally daily echocardiography while on ECMO

13. Follow-up, monitoring and detecting
complications during ECMO
 V-A ECMO follow-up
− Evaluation of aortic valve opening is paramount
− In periferal VA ECMO, afterload of retrograde aortic flow, will interfere with LV
ejection of stroke volume
− Left ventricular distention can arise, with secondary problems of increased wall
stress, trombus formation and pulmonary oedema
− LV distention may give need to LV decompression (IABP, Impella, percutaneous
or surgical vent)

14. Follow-up, monitoring and detecting
complications during ECMO
 V-A ECMO follow-up

15. Follow-up, monitoring and detecting
complications during ECMO
 V-A ECMO follow-up
− Cannula migration
− Pericardial effusion due to cannula trauma
− Signs of ventricular recovery

16. Follow-up, monitoring and detecting
complications during ECMO
 V-V ECMO follow-up
− Canula migration
− Check for recirculation (not only with echo…)
− Inadequate ECMO flow; check for cannula trombosis, and for relative/absolute
hypovolemia (often need for restrictive fluid therapy in ARDS)

17. Follow-up, monitoring and detecting
complications during ECMO
 V-V ECMO follow-up

18. Weaning from ECMO
 Weaning from V-V ECMO
− In presence of PFO/ASD, watch for acute pulmonary hypertension due to acute
hypercapnia, with secondary Re-Li shunting
− Evaluate RV function during weaning

19. Weaning from ECMO
 Weaning from V-A ECMO
− Lack of standardized protocols in literature
− Stepwise decrease in ECMO flow (to a certain percentage of ECMO flow, or to
about 1.5L/min), accompanied by echocardiographic evaluation
− At minimal ECMO flow, LVEF > 20-25%, VTI LVOT > 10cm and TDI lateral mitral
annulus peak systolic velocity (TDSa) > 6cm/s, are parameters associated with
weaning success

20. Reading suggestions / references
 Douflé G. et al. Echocardiography for adults supported with extracorporeal
membrane oxygenation. Critical Care (2015) 19:326
 Donker DW et al. Echocardiography in extracorporeal life support: a key player
in procedural guidance, tailoring and monitoring. Perfusion 2018. Vol 33 31-41
 Bunge J. et al. Right ventricular dysfunction during acute respiratory distress
syndrome and veno-venous extracorporeal membrane oxygenation. J. Thorac
Dis 2018; 10 (Suppl 5) 6 674-S682
 Bartko P. et al. Impact of Right ventricular performance in patients undergoing
extracorporeal membrane oxygenation following cardiac surgery. J. Am Heart
Assoc 2017;6 e005455
 Aissaoui N. Et al. Predictors of succesful extracorporeal membrane
oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock.
Intensive Care Med (2011) 37:1738-1745