Echocardiography for extracorporeal membrane oxygenation

Q: What is the clinical evidence from this study?

Study design: Review. Population: Cardiac and/or respiratory failure requiring extracorporeal membrane oxygenation (ECMO). Intervention: Echocardiography (transesophageal and transthoracic) for ECMO management.

Patrick Hussey; Gregory Von Mering; Navin C. Nanda; Mustafa I. Ahmed; Dylan R. Addis

doi:10.1111/echo.15266

January 7, 2022EchocardiographyOpen Access

Echocardiography for extracorporeal membrane oxygenation

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Key result

Echocardiography guides ECMO management from cannulation and LV venting through troubleshooting and weaning.

Why the study?

Guidelines for echocardiographic assessment in patients requiring extracorporeal membrane oxygenation (ECMO) are currently lacking.

Key Points

To review the clinical role, hemodynamic considerations, and technical applications of echocardiography before initiation, during cannulation, and throughout weaning in extracorporeal membrane oxygenation.
Narrative review evaluating transthoracic and transesophageal echocardiography protocols for patients undergoing extracorporeal cardiopulmonary support.
Assessed imaging techniques for anatomical screening, guidance of dual-lumen cannula placement, right ventricular monitoring, and indirect left ventricular venting.
Identified critical pre-cannulation anatomical targets, noting that identifying coronary sinus dilation (>1.5 cm) prevents persistent left superior vena cava cannulation and cardiac perforation.
Highlighted right ventricular assessment indices, showing that pulmonary artery acceleration times under 100 ms signal elevated pressures and fractional area change improves over single-plane metrics.
Emphasized the absence of formal interdisciplinary guidelines, underscoring the need for consensus protocols to standardize cannula positioning, troubleshooting, and weaning decisions.

Structured PICO

P

Population

Patients in cardiac and/or respiratory failure undergoing evaluation for, cannulation, monitoring, troubleshooting, or weaning of veno-venous (VV) or veno-arterial (VA) extracorporeal membrane oxygenation (ECMO).

I

Intervention

Comprehensive transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE), including 2D, 3D, biplane, and color flow Doppler imaging, to guide pre-ECMO assessment, single and dual-lumen cannula placement (Avalon Elite, Crescent MC3, ProtekDuo), left ventricular venting strategies (IABP, Impella, TandemHeart, LAVA-ECMO), troubleshooting, and weaning

This comprehensive narrative review outlines the critical role and technical considerations of echocardiography in pre-cannulation screening, guiding complex dual-lumen cannulation and left ventricular venting, troubleshooting, and weaning for patients on VV- and VA-ECMO.

Limitations

Currently, well-accepted and globally recognized clinical guidelines or echocardiography protocols to guide assessment and weaning of ECMO are lacking.
Accurate evaluation of tricuspid regurgitation to estimate pulmonary artery pressure is inhibited once ECMO flow is established due to drainage and reinjection of blood in the right atrium.
The utility of 3D echocardiography for right ventricular assessment in the context of ECMO remains unclear at present.
Left ventricular chamber size determined by TEE may be an insensitive indicator of ventricular distention, end-diastolic pressure, and left atrial pressure due to the nonlinear pressure-volume relationship within an intact pericardium.
Lack of well-accepted and globally recognized clinical guidelines or echocardiography protocols for ECMO assessment and weaning
Inability to reliably evaluate tricuspid regurgitation for pulmonary artery pressure estimation during active ECMO flow due to right atrial flow alterations
Unclear utility of 3D right ventricular analysis in the ECMO context
LV chamber size on TEE may be an insensitive indicator of ventricular distention and filling pressures due to the nonlinear LV end-diastolic pressure-volume relationship and pericardial constraints

Implication

Supports echocardiography integration in ECMO; leaves open prospective outcome trials.

Abstract

Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary life support for patients in cardiac and/or respiratory failure. Echocardiography provides essential diagnostic and anatomic information prior to ECMO initiation, allows for safe and efficient ECMO cannula positioning, guides optimization of flow, provides a modality for rapid troubleshooting and patient evaluation, and facilitates decision-making for eventual weaning of ECMO support. Currently, guidelines for echocardiographic assessment in this clinical context are lacking. In this review, we provide an overview of echocardiographic considerations for advanced imagers involved in the care of these complex patients. We focus predominately on new cannulas and complex cannulation techniques, including a special focus on double lumen cannulas and a section discussing indirect left ventricular venting. Echocardiography is tremendously valuable in providing optimal care in these challenging clinical situations. It is imperative for imaging physicians to understand the pertinent anatomic considerations, the often complicated physiological and hemodynamic context, and the limitations of the imaging modality.

Discussion

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Cite This Study

Hussey et al. (2022) conducted a review in Cardiac and/or respiratory failure requiring extracorporeal membrane oxygenation (ECMO). Echocardiography (transesophageal and transthoracic) for ECMO management was evaluated. Echocardiography provides essential diagnostic, anatomic, and hemodynamic guidance for ECMO initiation, complex cannula positioning, left ventricular venting, troubleshooting, and weaning.

synapsesocial.com/papers/6a75b57e20e137e1c1161af3 https://doi.org/10.1111/echo.15266

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Echocardiography for extracorporeal membrane oxygenation

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Echocardiography for extracorporeal membrane oxygenation

Key Points

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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