ECHOCARDIOGRAPHIC MONITORING ON ECMO

M.Mondino MD Dept.of Cardiac Anesthesia and CV-ICU

Niguarda Hospital, Milan

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.

Extra-Corporeal Membrane Oxygenation

• Patient selection

ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications• Decision making: cardiac recovery, weaning,

bridge to..

•Patient selection

ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications• Decision making: cardiac recovery, weaning,

bridge to..

Pt selection- Reversible causes of hemodynamic instability

V-A ECMO controindications

Aortic dissection Aortic valve regurgitation

Severe Arterial vascular disease

Absoulte controindicationscentral vs peripheralsurgical vs percutaneous

5

V-V ECMO controindications

Severe PulmonaryHypertension

Cardiac Failure

Pt selection

Consider VA-ECMO

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

Pt selectionRight Heart anomalies

Chiari’s network: review of the literature, Marios Loukas et al., Surg Radiol Anat (2010) 32:895–901

Chiari’s networkPt selection

Pt selection

The Internet Journal of Cardiology ISSN: 1528-834,”Isolated large atrial septal aneurysm and multiple ,”Isolated large atrial septal aneurysm and multiple cerebral infarcts:cerebral infarcts:Is there any association?” Is there any association?” Gerasimos Gavrielatos et al.

Interatrial septal aneurysm

Pt selectionAtrial septal defect (ASD) Patent foramen ovale (PFO)

•Patient selection

ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications• Decision making: cardiac recovery, weaning,

bridge to..

Insertion and correct placement of cannulas Echocardography can visualize the correct position of both wires and cannula.

Insertion and correct placement of cannulas 3d Echo

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.

Insertion and correct placement of cannulas VA ECMO

Insertion and correct placement of cannulas cVA-ECMO

The return cannula should be in the mid right atrium.

The access cannula tip should be in the proximal IVC.

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:

Insertion and correct placement of cannulas

V-V ECMO

-Ricirculation-Inadequate blood flow -Myocardial injury

Avalon cannulaIt 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

Insertion and correct placement of cannulas

•Patient selection

ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications• Decision making: cardiac recovery, weaning,

bridge to..

•Underlying LV dysfunction

Monitoring of the Pt on pVA-ECMO

Insuffiencent unloading of LV

• Increased afterload due to retrograde VA Ecmo flow

• Pulmonary congestion, oedema, hemorrhage.• Blood stagnation in LV• Myocardial injury (affecting recovery)

Adequate LV unloadingMonitoring of the Pt on pVA-ECMO

Echo Monitoring: - Myocardial contractility - LVEDV - Aortic Valve opening and Mitral Valve Reg.

AHF in DCMP, pVA ECMO (3 days) + Inotropes + IABP. WP=13, RAP= 8 mmHg

Adequate LV unloadingMonitoring of the Pt on VA-ECMO

15 yrs. male. Acute myocarditis, pVA-Ecmo (day1) + IABP + Inotropes

Adequate LV unloading is vital

Monitoring of the Pt on VA-ECMO

•Inotrops and vasodilators

•IABP

•Atrioseptostomie

•LV vent

• Anterograde and Retrograde LV unloading

Catena et al.,”Role of Echocardiography in the perioperative managment of mechanical circulatory support”. Best practice & Reserach Clinical Anaesthesiology 26 (2012)

Adequate LV unloadingMonitoring of the Pt on VA-ECMO

Adequate LV unloadingMonitoring of the Pt on VA-ECMO

Female, 2 ys; Fulminant myocarditiscVA ECMO (30 days) Bridged to recovery

Adequate Venous Pressure unloadingMonitoring of the Pt on VA-ECMO

Female, 43 ysLiver congestion in acute cardiac decompensation of HCMP

Adequate Venous Pressure unloadingMonitoring of the Pt on VA-ECMO

Hepatic vein flow

Before pVA ECMO During pVA ECMO

Monitoring of the Pt on V-V ECMO

Increases mixed SvO2

Decreases PVR

Decreases RV afterload

Increases coronaries O2 content

Increases LVEF

•Patient selection

ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications• Decision making: cardiac recovery, weaning,

bridge to..

ECMO Complications

Anticoagulation

Bleeding

Cannulas

Thrombosis FlowObstruction

Displacement

32

Intraventricular thrombosis is a well know complication ofmyocardial infraction. pECMO and LV akinesis can increasethis risk.

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. 2010;3(10):1049-1064.

ECMO Complications - Thrombosis

Obstruction of the IVC:

- Liver and splanchnic organs congestion

Obstruction of the SVC:

- SVC syndrome and reduced cerebral perfusion

ECMO Complications – Venous Flow obstruction

Obstruction of the IVC

ECMO Complications - Flow obstruction

Venous Flow obstruction

TamponadeECMO Complications - Bleeding

Pericardial effusion might became evident when Ecmo support is reduced.

•Interatrial septum

•Coronary sinus

•Across the tricuspid valve

•Through a patent foramen ovale and into the LV

ECMO Complications Cannula malposition

Augoustides J et al.. J Cardiothorac Vasc Anesth 17:113-120, 2003

Atrial septal aneurysm occluding the inflow cannula.

ECMO Complications - Cannula malposition

•Patient selection

ECHOCARDIOGRAPHIC MONITORING ON ECMO

• Insertion and correct placement of cannulas

• Monitoring during support

• Detecting complications• Decision making: cardiac recovery, weaning,

bridge to..

clinicalclinicaljudgmejudgme

ntnt

Weaning and Recovery

There are no established weaning guidelines

IF and WHEN

BTR, BTB, BTVAD, BTTx, BT?

hemohemodynamicdynamicparametparamet

ersers

EchoEchovariablesvariables

Echocardiographic parameters of possible recovery

•LVEF > 35-40%•LVED diameter < 55mm•Aortic velocity-time integral >10 cm•Aortic Valve opening pattern•Absence of LV dilatation

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.

Weaning and Recovery

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.

michelegiovanni.mondino@ospedaleniguarda.it

Thank YouThank You

Niguarda Hospital 1950