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Using TEE in ECMO Deployment: Problems with VV and VA ECMO

Robert M. Savage, MD, FACC


Vice-Chair, Department of Cardiothoracic Anesthesia & Critical Care
Anesthesiology and Heart & Vascular Institutes
Cleveland Clinic Healthcare System
Cleveland Ohio

Objectives
Upon completion of this lecture, the participant will have an understanding of the:
Definition, classification, and indication for the different types of ECMO
Role of ECMO in critical care and clinical outcomes
TEE assessment of ECMO deployment, maintainance, & weaning
Role of TEE in troubleshooting ECMO problems & complications

ECMO: Definition and Classification


Extracorporeal membrane oxygenatin (ECMO) is an advanced strategy increasingly used to support the
respiratory and cardiac function of patients with refractory respiratory and/or cardiac failure. ECMO may be used
for a few days to support patients with temporarily stunned myocardium with cardiogenic shock or for months in
patients with irreversible cardiopulmonary dysfunction as a bridge to heart or lung transplantation. The ECMO
circuit consists of a cannula for venous blood drainage, a blood pump, a gas exchange device (oxygenation & CO2
clearance), a thermal control unit, and a cannula for return of oxygenated blood to the patient's venous or
systemic arterial system. ECMO is classified as either Veno-Veno (VV) for use in isolated respiratory failure
(without RV/LV dysfunction or pulmonary hypertension) or Veno-Arterial (VA) for patients in cardiogenic shock
and associated respiratory dysfunction. VV ECMO drains venous blood via a RA or IVC cannula, performs gas
exchange, and returns blood to a functioning right heart. VA ECMO uses a similar RA or IVC cannula to drain
venous blood which is then oxygenated, cleared of CO2, and returned to the systemic circulation via femoral or
central arterial cannulation.

ECMO: Role in Critical Care (Indications, Contraindications) & Outcomes


The indications for VV ECMO in acute respiratory failure with preserved cardiac function include viral or bacterial
pneumonia, SIRS, ARDS, status asthmatacus, traumatic pulmonary contusions, and massive intrapulmonary
hemorrhage. VV ECMO may also be used intraoperatively during tracheo-bronchial resections along with jet
ventilation. The indications for VA ECMO in cardiogenic shock with associated respiratory dysfunction include
"failure to rescue" from cardiopulmonary arrest, cardiogenic shock, inability to wean from CPB, bridge to heart
transplant, catastrophic pulmonary embolism, sepsis with myocasrdial depression, myocarditis, and drug overdose
with associated cardiac depression. VA ECMO has also been used in the cath lab in higher riskpatients undergoing
percutaneous interventions. Contraindications for all forms of ECMO include severe neurologic injury,
intracerebral hemorrhage, or chronic irreversible disease in patients not considered candidates for transplantation.
VV ECMO is not an option in patients with severe RV or LV dysfunction, severe PHTN, or following
cardiopulmonary arrest. Contraindications for VA ECMO are limited to patients with untreated aortic dissections
or severe aortic regurgitation. With growth of VA and VV ECMO, an increasing number of centers sre reporting
their clinical experience and outcomes. Mohr et al reported a series of 219 consecutive patients with postcardiotomy cardiogenic shock over a 5 year period. The mean duration of VA ECMO was 2.8 days with 134 patients
(60%) successfully weaned and 52 (24%) discharged from the hospital at 30 days. Cheng et al performed a metaanalysis of 1529 patients receiving VA ECMO for cardiogenic shock with a cummulative survival-to-discharge of 534
(35%). UPMC reported a series of patients with VV or VA ECMO for PHTN and RV dysfunction with a 30 day
survival of 34%. Mason et al described a series of 51 patients with VV ECMO as a bridge to lung transplant with a 2
year survival of 45%. UPMC reported a similar group of 44 patients using ECMO as a bridge to LTP. Though 11
patients (25%) expired before transplant, 33 (75%) were transplanted with 25 (76%) surviving beyond 2 years.

TEE Assessment: ECMO Deployment, Maintainance, & Weaning


TEE plays an integral role in guiding the management of patients undergoing ECMO imcluding (1)cannulation and
ECMO initiation, (2) monitoring during ECMO, (3) ECMO troubleshooting and detection of complications, and (4)
weaning from ECMO. Prior to ECMO deployment, a thorough TEE is essential for identifying reversible causes of
clinical deterioration (cardiac tamponade, hypovolemia, RV or LV dysfunction, under-diagnosed valve dysfunction),
presence of contraindications for ECMO (aortic dissection or severe AR) or issues interfering with correct pls
placement of cannula, or ECMO function (ASD, PFO, Chiari Network, prominent Eustachial valve, persistent
leftisided SVC, RA thrombi, or TV Stenosis). The pre-ECMO TEE may assist in guiding the choice of ECMO to a VA
configuration with the presence of significant RV dysfunction, pulmonary HTN, TR, or acute PE. The presence of
severe LV dysfunction, MR, or greater than mild AR may indicate the need for an LV vent to avoid LV distension or
a percutaneous bicaval venous cannula to ensure complete emptying of the RV. During cannula insertion for VV
ECMO, TEE is useful in guiding the positioning of the venous inflow cannula to the IVC proximal to the RA. The
oxygenated ouitflow cannula is positioned in the RA with flow directed across the TV. TEE ensures that neither
cannula is positioned in the coronary sinus or across a PFOor ASD. If the dual VV Avulon right internal jugular
cannula is used, TEE is used to position the distal tip at the cavoatrial junction with the oxygenated outflow port
directed across the tricuspid valve. Precise positioning of this cannula avoids the potential of recirculatimg
oxygenated blood into the venous outflow cannula. With TEE's superior image quality, it's more reliable than TTE
for positioning the venous cannula in its correct location. Chest x-ray is not real-time or accurate enough to guide
positioning of the cannula. In VA ECMO, TEE identification of the guide wire in the aorta before dilitation of the
femoral artery ensures the arterial cannula will not be placed retroperitoneally or into the wall of the aorta leading
to a retrograde aortic dissection.

TEE Troubleshooting: Problems & Complications


Ventricular distension & pulmonary congestion: Because of increased aortic afterload with femoral arterial inflow, TEE monitoring is essential when initiating peripheral fem-fem VA ECMO to ensure aortic valve opening
and the absence of LV distension. If the LV distends on initiation of VA ECMO, immediate decompression with a
LV vent or atrial baloon septostomy, is necessary to avoid distending the LV with development of severe MR, LA
distension, and florrid pulmonary edema. Failure of the aortic valve to open with VA ECMO predisposes
thrombus formation on aortic valve cusps necessitating additional anticoagulation.
Caunnula malposition or migration & recirculation: With right internal jugular insertion of the single dual lumen
cannula for VV ECMO, the tip is positioned above the IVC-RA junction with care to avoid obstruction of the
hepatic vein at its insertion into the IVC. Oxygenated blood flow from the outflow lumen must be precisely
directed across the TV to avoid hypoxemia related to recirculation of oxygenated blood into the venous inflow
cannula. Migration of the cannula with minimal patient repositioning or movement may reduce the distance
between the venous inflow & outflow cannula resulting in similar recirculation. Interrogation of this area with
CFD or PWD will detect recirculation. Recirculation of oxygenated blood into the inflow cannula brightens the
color of blood in the lumen to a shade similar to the oxygenated venous outflow cannula.
Budd-Chiari Syndrome: Positioning the femoral venous drainage cannula in the IVC may obstruct from the
hepatic vein into the IVC with increased flow velocities (> 1.5 m/sec). This obstruction reduces hepatic venous
drainage with hepatic congestion and associated abnormalities in liver enzymes. TEE positioning of cannula
below the hepatic vein-IVC insertion relieves obstruction and any associated hepatic congestion.
RV rupture & tamponade: When using the dual lumen single venous cannula, the tip may migrate across the TV
causing increased TR. With further migration, trumatic rupture of the RV free wall has been reported.
Upper Body Hypoxemia Syndrome: In setting of peripheral fem-fem VA ECMO with pulmonary dysfunction
with poor oxygenation, incomplete emptying of the RV increases the volume of desaturated blood flowing into
the left heart. The enhanced preload increases cardiac output with desaturated blood which impeeds flow of
oxygenated blood up the aorta from the femoral artery. With more deoxygenated blood flowing to upper body
and head, patient develops a bluish discoloration of head while lower extremities appear pink. This distinct
coloration is referred to as the "Upper Body Hypoxemia", "North-South", or "Harlequin" Syndrome.

Thrombosis (spontaneous contrast): With prolonged VA ECMO, low or stagnant flow evidenced by spontaneous
contrast leads to formation of clot on the cannula andvalve structures. Adjusting ECMO flows, increasing
anticoagulation, or decompressing a distended LA or LV may decrease propensity for clot formation.

ECMO Weaning
VV ECMO: Weaning of VV ECMO is guided largely by changes in oxygenation and pulmonary compliance.
Successful weaning is probable if oxygenation and PA pressures do not deteriorate as ECMO flow is progressively
decreased by 0.5 L/min flows over 5 minute intervals. CWD interrogation of a TR jet enables estimation of the
PA systolic pressure. Marked elevation of PA pressures during VV ECMO weaning may result in RV dilitation,
diminished global RV function, and increasing severity of TR.
VA ECMO: TEE is more consistently used to guide the weaning process in VA ECMO. TEE assessment of LV
Ejection Fraction, LVEDD, severity of MR, and calculated LV stroke volume during progressive 0.5 lpm reductions
of VA ECMO circuit flows guides the weaning process over successive 5 minute intervals. Caution must be taken
to not reduce ECMO flows below 1 lpm for prolonged periods without increasing risk of clot formation in the
circuit.

Conclusion:
Transesophageal Echocardiography is the quintesential diagnostic imaging technology guiding physicians through
the minefield of critical decisions made for patients requiring ECMO. Compared to TTE and other sophisticated
fixed imaging techniques, TEE provides a higher resolution of 2&3D imaging and CFD, inaddition to accurate
quantitative Doppler capabilities. Because of it's ready availability, portability, cost-effectiveness, and easy to
use, TEE it is the navigator of choice providing crucial information for the period surrounding ECMO deployment
including: 1) selection of patients, 2) recognition of reversible causes of deterioration, 3) determining appropriate
ECMO configuration, 4) identifying contraindications, 5) guiding cannula placement & confirming precise location,
6) monitoring the initiation & maintainance of ECMO support, 7) recognition of complications, and 8) guiding the
timing & process of weaning. For centers employing VV & VA ECMO treatment strategie's for their patients, the
24-7 availability of critical care specialists with competency in advanced perioperative echocardiography is a
mandatory immutable prerequisite to ensue the quality and safety of care provided to their patients.
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