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ECHOCARDIOGRAPHIC MONITORING ON ECMO

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

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ECHOCARDIOGRAPHIC MONITORING ON ECMO

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

  2. 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.

  3. ECHOCARDIOGRAPHIC MONITORING ON ECMO • Patient selection • Insertion and correct placement of cannulas • Monitoring during support • Detecting complications • Decision making: cardiac recovery, weaning, bridge to..

  4. ECHOCARDIOGRAPHIC MONITORING ON ECMO • Patient selection • Insertion and correct placement of cannulas • Monitoring during support • Detecting complications • Decision making: cardiac recovery, weaning, bridge to..

  5. Pt selection • - Reversible causes of hemodynamic instability • V-A ECMO controindications • Aortic dissection • Aortic valve regurgitation • Severe Arterial vascular • disease Absoulte controindications central vs peripheral surgical vs percutaneous 4

  6. Pt selection V-V ECMO controindications Severe Pulmonary Hypertension Cardiac Failure Consider VA-ECMO

  7. Pt selection Right Heart anomalies • atrial septal defect • interatrial septal aneurysm • patent foramen ovale • prominent Chiari network • pacemaker or ICD leads

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

  9. 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.

  10. Pt selection Atrial septal defect (ASD) Patent foramen ovale (PFO)

  11. ECHOCARDIOGRAPHIC MONITORING ON ECMO • Patient selection • Insertion and correct placement of cannulas • Monitoring during support • Detecting complications • Decision making: cardiac recovery, weaning, bridge to..

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

  13. Insertion and correct placement of cannulas 3d Echo

  14. 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.

  15. Insertion and correct placement of cannulas VA ECMO

  16. Insertion and correct placement of cannulas cVA-ECMO

  17. 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.

  18. 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

  19. 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

  20. ECHOCARDIOGRAPHIC MONITORING ON ECMO • Patient selection • Insertion and correct placement of cannulas • Monitoring during support • Detecting complications • Decision making: cardiac recovery, weaning, bridge to..

  21. Monitoring of the Pt on pVA-ECMO • Increased afterload due to retrograde VA Ecmo flow • Underlying LV dysfunction Insuffiencent unloading of LV • Pulmonary congestion, oedema, hemorrhage. • Blood stagnation in LV • Myocardial injury (affecting recovery)

  22. Monitoring of the Pt on pVA-ECMO Adequate LV unloading AHF in DCMP, pVA ECMO (3 days) + Inotropes + IABP. WP=13, RAP= 8 mmHg • Echo Monitoring: • - Myocardial contractility • - LVEDV • - Aortic Valve opening and Mitral Valve Reg.

  23. Monitoring of the Pt on VA-ECMO Adequate LV unloading 15 yrs. male. Acute myocarditis, pVA-Ecmo (day1) + IABP + Inotropes

  24. Monitoring of the Pt on VA-ECMO Adequate LV unloading is vital • Inotrops and vasodilators • IABP • Atrioseptostomie • LV vent • Anterograde and Retrograde LV unloading

  25. 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)

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

  27. Monitoring of the Pt on VA-ECMO Adequate Venous Pressure unloading Female, 43 ys Liver congestion in acute cardiac decompensation of HCMP

  28. Monitoring of the Pt on VA-ECMO Adequate Venous Pressure unloading Hepatic vein flow Before pVA ECMO During pVA ECMO

  29. Monitoring of the Pt on V-V ECMO Increases mixed SvO2 Increases coronaries O2 content Decreases PVR Decreases RV afterload Increases LVEF

  30. ECHOCARDIOGRAPHIC MONITORING ON ECMO • Patient selection • Insertion and correct placement of cannulas • Monitoring during support • Detecting complications • Decision making: cardiac recovery, weaning, bridge to..

  31. ECMO Complications Anticoagulation Cannulas Bleeding Thrombosis Displacement Flow Obstruction

  32. ECMO Complications - Thrombosis Intraventricular thrombosis is a well know complication of myocardial infraction. pECMO and LV akinesis can increase this risk.

  33. 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.

  34. ECMO Complications – Venous Flow obstruction • Obstruction of the IVC: • - Liver and splanchnic organs congestion • Obstruction of the SVC: • - SVC syndrome and reduced cerebral perfusion

  35. ECMO Complications - Flow obstruction Obstruction of the IVC

  36. Venous Flow obstruction

  37. ECMO Complications - Bleeding Tamponade Pericardial effusion might became evident when Ecmo support is reduced.

  38. ECMO Complications Cannula malposition • Interatrial septum • Coronary sinus • Across the tricuspid valve • Through a patent foramen ovale and into the LV

  39. ECMO Complications - Cannula malposition Atrial septal aneurysm occluding the inflow cannula. Augoustides J et al.. J Cardiothorac Vasc Anesth 17:113-120, 2003

  40. ECHOCARDIOGRAPHIC MONITORING ON ECMO • Patient selection • Insertion and correct placement of cannulas • Monitoring during support • Detecting complications • Decision making: cardiac recovery, weaning, bridge to..

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

  42. Weaning and Recovery 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

  43. 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.

  44. 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.

  45. michelegiovanni.mondino@ospedaleniguarda.it Thank You Niguarda Hospital 1950

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