2 - Advanced ECMO Management Strategies.pdf

Echocardiography for
Extracorporeal Membrane Oxygenation
Adam A. Dalia, MD, MBA, FASE
Assistant Professor, Harvard Medical School
Director of Clinical Operations and Perioperative Echocardiography
Division of Cardiac Anesthesiology, Massachusetts General Hospital
@adalia513

Disclosures
● None relevant to this presentation

Objectives
● Detailing the role of Echocardiography for adult ECMO patients
● Utilizing Echo for Cannula insertion/positioning guidance
● Patient Monitoring during ECMO support

Role of Echocardiography in ECMO
● Pre-ECMO Assessment
○ Identifying or confirming pathology
○ Rule out contraindications for ECMO
○ Assist in Cannulation
● Intra-ECMO Assessment
○ Troubleshooting flows during ECMO
○ Evaluating readiness to wean from ECMO
● Post-ECMO Assessment

Continuous Cardiac Monitoring
Disposable transesophageal probe (Imacor®)
J Thoracic CardiovascSurg.2013;146:1474–9

R/O Contraindications
LV
LA
Ao

Echocardiography during ECMO Cannulation
● Pathology impacting access
○ Atheromatousdisease
○ Peripheralvasculardisease
● Pathology that may impact function of venous cannula
○ Intracardiacshunt
○ Venousmass/clot
○ Chiari network
○ PPM/ICD leads
○ Persistent LSVC
Case Reports in Cardiology. 2016;2016:1-3.
Clinical Manual andReviewofTransesophagealEchocardiography, 2nd Edition

Case 1: Venous Cannula
Hepatic IVC

Case 1: Venous Cannulation
LA
RA
SVC
IVC

Venous Cannula Malposition
● Inappropriate depth/outflow misdirected
● Abutting/through the interatrial septum
● Traversing tricuspid valve/right ventricle
● Hepatic veins
● Right atrial appendage or coronary Sinus
● Perforation (RA or RV)

Complications during Cannulation
RA
LA
IAS

Guidewire Misdirection
RV
RA
LA
LV

Case 1: Complications during Cannulation
RV
LV

Case 2: High line Pressures
LA
RV
RA
PV
AV

Case 2: High line Pressures-Low Flow
LV
LA
Ao
AV

Case 2: High line Pressures-Low Flow
Ao
False
Lumen

Case 2
LA
LV
MV
https://www.abiomed.com/impella/impella-50

● Identifying adequate left ventricular decompression
○ May require venting (Impella, atrial septostomy, surgical vent)
● Aortic Valve function
○ Confirming pulsatility
● Monitoring for intracardiacthrombi formation
○ Spontaneousecho contrast or smoke
○ LV or LA thrombusin particular
● Cannula position/Troubleshooting
Echocardiography during VA-ECMO
J Cardiothorac Vasc Anesth. 2019;33(5):1325-1330.

Weaning from VA ECMO
● LV size and function
○ LVEDD (< 65mm)
○ LVOT VTI (>10cm) and EF (>20-25%)
○ S wave at lateral annulus (> 6cm/s)
● Monitoring RVresponse to new loading conditions
○ RVSP and degree of TR
● Full assessmentduring clamping
○ Very brief due to anticoagulation

Case 3: Avalon Cannula
LA
RA
SVC
IVC
Banfi C, et al. J Thorac Dis. 2016;8(12):3762-3773.

Echocardiography during VV ECMO
● Right Ventricular Monitoring
○ RV:LV end-diastolic area
○ Tricuspid annular plane systolic excursion (TAPSE)
○ Tissue Doppler peak systolicvelocity at the lateral annulus.
○ RV Strain
● Cannula position
○ Troubleshooting Flow
○ Thrombi
● LV function
○ Echo derived C.O. at the LVOT

Weaning from VV ECMO
● Evaluating RV function and size
○ TAPSE
○ FAC
○ S’ at tricuspid annulus
● Degree of tricuspid regurgitation
CritCare. 2015;19:326.

https://www.elso.org/resources/guidelines.aspx
Future Research- ELSO Guidelines

Summary
Echocardiography useful in all facets of the peri-ECMO period:
● Confirm diagnosis
● Rule out contraindications
● Guide cannulation
● Cardiac monitoring while on ECMO
● Help troubleshoot complications
● Weaning tool
● Post ECMO Injuries

References
Sorokin V, Maclaren G, VidanapathiranaPC, Delnoij T, Lorusso R. Choosing the appropriateconfiguration and cannulation strategies for extracorporeal
membraneoxygenation: the potential dynamic process of organ supportand importance of hybrid modes. Eur J Heart Fail. 2017;19 Suppl2:75-83.
Krishnan S, SchmidtGA. Hemodynamic monitoring in the extracorporealmembraneoxygenation patient. Curr Opin Crit Care. 2019;25(3):285-291
NakasatoGR, MurakamiBM, Batistão gonçalves MA, Lopes JL, Lopes CT. Predictors of complications related to venoarterial extracorporealmembrane
oxygenation in adults: A multicenter retrospectivecohortstudy. HeartLung. 2020;49(1):60-65.
Banfi C, PozziM, Siegenthaler N, et al. Veno-venous extracorporealmembraneoxygenation: cannulation techniques. J Thorac Dis. 2016;8(12):3762-3773.
LafçıG, Budak AB, Yener AU, Cicek OF. Use of extracorporealmembraneoxygenation in adults.HeartLung and Circ 2014;23:10-23.
GriffeeMJ, Tonna JE, Mckellar SH, Zimmerman JM. Echocardiographic Guidanceand Troubleshooting for Venovenous ExtracorporealMembrane
Oxygenation Using the Dual-Lumen Bicaval Cannula. J Cardiothorac Vasc Anesth. 2018;32(1):370-378.
GriffeeMJ, Zimmerman JM, Mckellar SH, Tonna JE. Echocardiography-Guided Dual-Lumen Venovenous ExtracorporealMembraneOxygenation Cannula
Placement in the ICU-A RetrospectiveReview. J Cardiothorac Vasc Anesth. 2019;
Ortoleva JP, Dalia AA, Fiedler AG, et al. Echocardiographic Assessmentof Biventricular Function in 249 Patients During the Peri-ExtracorporealMembrane
Oxygenation Period. J Cardiothorac Vasc Anesth. 2019;33(5):1325-1330.
Douflé G, RoscoeA, Billia F, Fan E. Echocardiography foradultpatients supported with extracorporealmembraneoxygenation. CritCare. 2015;19:326.

The Awake, Extubated
ECMO Patient
Phillip Mason, MD
Univ Texas Health Science Center at San Antonio

The Awake, Extubated
VV ECMO Patient
Phillip Mason, MD

The Awake, Extubated,
Ambulatory, VV ECMO
Patient
Phillip Mason, MD

“Wake the
patients, you
must.
And walk
them.”

Crit Care 2014 ASAIO J 2015
J Thorac Cardiovasc Surg 2018
Crit Care Med 2018
Ann Thor Surg 2019
Ambulation With Femoral Cannulas is Safe!

Delirium
Agitation
Hypoxemia
&
Circuit Chatter
Sedation
Pathway to failure

This is your BRAIN
This is VERSED

This is your BRAIN on
VERSED!!!
Any questions?
JUST SAY NO

www.EDECMO.org www.reanimateconference.com

ECMO with normal cardiac output
ECMO
ECMO
5 LPM
Cardiac
Output
5 LPM
Venous
Return
5 LPM
O2 transfer
250 ml/min

ECMO with hypoxemia
ECMO
ECMO
5 LPM
Cardiac
Output
10 LPM
Venous
Return
10 LPM
Venous
admixture
O2 transfer
250 ml/min
STILL

The Power of Human Interaction

Liberation from ECMO
Craig Rackley, MD
Associate Professor of Medicine
Division of Pulmonary and Critical Care
Duke University Medical Center

Disclosures
• Inspira – Consulting
• Becton Dickinson – Consulting
• Select Medical – Medical Advisory Board

Weaning: accustom
(someone) to
managing without
something on which
they have become
dependent.

Liberation: the act of
setting someone free.

Spontaneous Breathing Trials
N Engl J Med. 1995;332(6):345.
N Engl J Med. 1996;335(25):1864.
1980s and 1990s: the era of ventilator WEANING…
Today: the era of ventilator LIBERATION

Spontaneous Awakening Trials
1990s and 2000s: the era of sedation WEANING…
Today: the era of Sedation Interruption…
N Engl J Med. 2000;342(20):1471.

Wake up and Breathe!
Lancet. 2008;371(9607):126.

Our Experience in Liberation from VV-ECMO

SAT, SBT, …. and SOT(Sweep Off Trial)
Crit Care Explor. 2021 Dec; 3(12): e0584.

Clear protocol = shorter time on ECMO
Crit Care Explor. 2021 Dec; 3(12): e0584.

How have we continued to improve??

Key Points
• Set objective criteria to qualify for trial off ECMO
• Define method for testing trial off ECMO
• Set objective criteria for failing trial off ECMO
• Let the physician know when everything has been done..

2 - Advanced ECMO Management Strategies.pdf

2 - Advanced ECMO Management Strategies.pdf

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2 - Advanced ECMO Management Strategies.pdf