B52-05 Assessment of Venous Congestion Using Hepatic and Portal Vein Doppler to Assess Suitability of Weaning From Veno-arterial ECMO

Abstract Rationale During VA-ECMO weaning, intravascular volume status and venous congestion are difficult to ascertain using conventional hemodynamic parameters such as CVP and PAOP. Hepatic and Portal Venous Doppler waveforms can provide dynamic and real-time assessment of right–sided filling pressures, central volume overload, valvular, and systolic function; but its role in ECMO weaning is not well described Methods We initiated a prospective, physiology-guided feasibility study that integrates hepatic and portal vein Doppler into VA-ECMO weaning alongside invasive monitoring and echocardiography. Prespecified checkpoints during stepwise flow reduction included perfusion, CVP, pulmonary pressures, IVC collapsibility, Biventricular function, and hepatic and Portal Doppler waveforms. Decannulation required concordance across modalities and stable end-organ function. We present a case series that highlights the role of Doppler waveforms. Results A 74-year-old woman with HFpEF, CKD G3b, atrial fibrillation, diabetes, and asthma underwent elective multivessel PCI that was complicated by PEA arrest with return of spontaneous circulation in four minutes and cardiogenic shock despite patent stents. VA-ECMO and an intra-aortic balloon pump were initiated on day 0. On day 3, we performed a protocolized weaning trial from 2.5 to 0.5 L/min. As flows decreased, CVP remained borderline and pulmonary pressures rose modestly. Hepatic vein waveforms remained S-dominant with preserved systolic forward flow, and portal pulsatility stayed low, indicating preserved venous outflow with low-grade systemic congestion. These findings were concordant with improving perfusion and urine output and supported readiness for decannulation. VA-ECMO was removed on day 4. A subxiphoid pericardial window addressed a moderate effusion. The intra-aortic balloon pump was removed on day 5. Echocardiography on day 6 showed preserved LVEF of 50 to 55 percent without right ventricular dilation. The hospital course included multifocal ischemic strokes recognized during sedation wean that were managed with antithrombotic therapy, improving renal function without dialysis, resolving shock-related liver injury, a PEG for dysphagia, extubation on day 13, and discharge to rehabilitation on day 30. Conclusions In this initial case from an ongoing feasibility study, hepatic and portal venous Doppler complemented invasive metrics, clarified venous congestion physiology during VA-ECMO flow reduction, and supported safe decannulation despite borderline CVP and modest increases in pulmonary pressures. Bedside venous Doppler may enhance ECMO weaning decisions and help mitigate volume-related complications. Continued enrollment will evaluate standardized Doppler-guided criteria and associations with renal, neurologic, and hemodynamic outcomes. This abstract is funded by: None