2022 Conference hemodynamic monitoring in VA ECMO. Internacional Young Academy of Cardiology "Back to the basics" course.

2. European Society of Intensive Care Medicine
ESCIM Cardiovascular Dynamics section
ESC-Association for Acute CardioVascular Care
Hemodynamic monitorization of the
patient during VA- ECMO support
Dr. Chacón-Lozsán Francisco J. MD, MEd.
Critical Care Medicine-Venezuelan Central University
ESCIM CD section Representative Clinical Training Committee
francisco.lozsan@mkardio.hu
2022

3. Conflict of interest: None

4. Content:
• Hemodynamic changes CS
• Hemodynamic effects of VA ECMO
• Physical principles of hemodynamic
monitoring during VA ECMO.
• Functional Hemodynamic monitoring
• Tools for monitorization

5. Hemodynamic changes during CS
Physiology for Anaesthetists. (2019), 136–140. doi:10.1017/9781108565011.034

6. Hemodynamic changes during CS
Furer, A., Wessler, J., & Burkhoff, D. (2017). Hemodynamics of Cardiogenic Shock. doi:10.1016/j.iccl.2017.03.006
↓ Contractility
↓Stroke volume
↑EDV
NH adrenergic activation
↑Heart rate
↑Vasoconstriction
Mobilization blood from an unstressed
to a stressed compartment
↑Blood pressure
↓Stroke volume
↑LVEDV

7. RV function
↓ Contractility
↓Stroke volume
↑RVEDV
↓PVR
Lala, A et al (2018). Doi:10.1016/j.cardfail.2017.10.009
Hemodynamic changes during CS

8. Hemodynamic changes during CS

9. Hemodynamic effects of VA ECMO
A: VA ECMO on RV
↓RVEDV
↓RV SV
B: VA ECMO on LV
↑SVR (MAP and Perfusion)
As ECMO flow ↑:
↓ Pulse pressure
↓ LV SV
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

10. Physical principles of hemodynamic monitoring
during VA-ECMO
The main role of VA-ECMO support is to provide adequate blood flow
and oxygen supply to maintain optimal global tissue perfusion.
Molecular and Cellular Biochemistry (2021) 476:1313–1326 https://doi.org/10.1007/s11010-020-04019-8

11. Good
Perfusion
VO2
CaO2-CvO2 CO
Total
DO2
ECMO
DO2
Qecmo
Gas
flow
Systemic
DO2
CO
HR SV
Preload
(CVP, IVC,
LVEDA, RVEDA)
Contractility
(CPI, EF)
Afterload
(SVR,
elastance)
CaO2
Hb PaO2 SO2
Physical principles of hemodynamic monitoring
during VA-ECMO
BALANCE
Interdependent

12. Functional Hemodynamic monitoring
Functional Hemodynamic Monitoring is the assessment of the
dynamic interactions of hemodynamic variables in response to a
defined perturbation, that greatly increase the ability of these
measures to define cardiovascular state and predict need for and
response to therapy.
PRECISION MEDICINE

13. Tools for monitorization
Variable Parameters Considerations
Afterload 1. Diastolic pressure
2. MAP
1. Good correlation with LV afterload.
2. Since MAP is a product of total CO and SVR. In VA-ECMO
patients, MAP increases may be achieved by increasing
either CO (monitored by ECMO flow and native CO) or SVR
Contractility 1. CO and CI
2. CPI
3. LVEF
4. PP
1. Needed to estimate DO2/VO2, ECMO flow support
(Qecmo/CO) and cardiac function.
2. Better parameter for cardiac systolic function
3. Helps to follow up, easy to assess by TTE
4. Increasing PP is a sign of LV recovering
Right ventricle
(please don’t forget it)
1. TAPSE
2. FAC
3. RV/LV diameter
4. TAPSE/PASP
1. Easy to do using TTE
2. Good correlation with RV systolic function
3. Good predictor of RV failure
4. Good predictor of mortality for RV failure
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

14. Tools for monitorization
Variable Parameters Considerations
Perfusion 1. MAP
2. NIRS
3. Urine output
4. Lactate
5. SvO2/SvcO2
6. CRT/skin mottling
1. MAP is a product of total CO and SVR. In VA-ECMO
patients, MAP increases may be achieved by increasing
either CO or SVR, using vasoactive drugs. As total CO is
composed of VA-ECMO flow and native CO, increasing
ECMO flow or native CO could increase MAP. MAP and
should be adjusted according to individual circumstances. As
MAP increases are related to increases in afterload,
balances between the effects of increased afterload and
adequate tissue perfusion should be weighed.
2. Helps monitoring cerebral and low extremities perfusion
3. Needs hourly evaluation in order to observe early changes
and give therapy, in places with low personal its hard to do it.
4. Level changes after ECMO initiation help monitoring therapy
response
5. Difficult to interpret, pCO2 gap and detailed invasive
hemodynamic monitoring may serve as complementary tools
to assess the hemodynamic status
6. Bedside, may predict poor outcome.
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

15. Tools for monitorization
Variable Parameters Considerations
Preload 1. CVP
2. RVEDA or LVEDAi
3. IVC
1. Static barometric parameter, needs to be observed
over time to stablish reference range. During VA
ECMO CVP is low due to continuous venous
drainage during VA-ECMO support. Higher CVP in
the VA-ECMO setting could hint at venous
congestion or ventricle dysfunction.
2. In absence of GEDV, using TTE, TEE its very good
tool.
3. May give false negatives by hindrance to IVC size
change (ECMO cannulae).
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

16. Tools for monitorization
Variable Parameters Considerations
Preload
responsiveness
(VR)
1. PPV, SVV
2. IVCDV
3. PLR
1. May loss ability to prediction in low tidal volume
but can be indexed by variation of transpulmonary
pressure.
2. May loss ability to predict VR due to hindrance to
IVC size change (ECMO cannulae).
3. Really good and easy to do, may be challenging in
patients with ECMO support with femoral cannula,
not helpful in patients with increased intracranial
pressure
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

17. Tools for monitorization
ΔVTI induced by Trendelenburg maneuver to predict fluid responsiveness was 0.93
[95% confidence interval (CI) 0.81–0.98], with a sensitivity of 82% (95% CI 60–95%), and
specificity of 88% (95% CI 64–99%), at a best threshold of 10% (95% CI 6–12%).
Luo et al. Ann. Intensive Care (2021) 11:16 https://doi.org/10.1186/s13613-021-00811-x

18. Tools for monitorization
Variable Considerations
Pulmonary artery
catheter (PAC)
• Although the PAC has limitations for CO measurements
during VA-ECMO, it still provides valuable hemodynamic
information such as PAWP, which is one of the indicators for
LV distention
Transpulmonary
thermodilution (TPTD)
• Volumetric parameters calculated by TPTD may be
inaccurate
• Cold saline injected through central catheter could be
drained by ECMO cannula or mixed with ECMO blood flow
• Extracorporeal circulation affects pulmonary blood flow
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

19. Tools for monitorization
Variable Considerations
Arterial pulse-wave
analysis (APWA)
• APWA systems become unreliable when major
hemodynamic or vasomotor tone changes exist. VA-ECMO
patients often experience large changes in arterial
resistance, either spontaneously or due to vasopressors,
and can present little-to-no pulsatility
Echocardiography • Recommended as the first-line evaluation tool in patients
with VA-ECMO
• Measures CO and CI by VTI at LVOT
• Only intermittent measurements
• Non invasive
• High operator dependency
• TTE depends on good acoustic window, TEE can be more
invasive
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

20. Tools for monitorization
Some special issues during VA ECMO
Ann Transl Med 2020;8(12):792 | http://dx.doi.org/10.21037/atm.2020.03.186

21. Monitorization of a
patient under VA
ECMO support must be
objective and
multimodal.

22. And still this is just watching
by the keyhole…

23. Francisco J. Chacón-Lozsán, MD, MEd
http://ve.linkedin.com/in/chaconlozsanfrancisco
francisco.lozsan@mkardio.hu
Thanks for your attention
Gracias por su atención
Köszönom a figyelmet