VA-ECMO Weaning in Low-Flow Low-Gradient Aortic Stenosis Post STEMI and ECPR

Figures

• 

  Visual Summary. VA-ECMO Complicates the Assessment of AS Severity and Readiness for Weaning A multimodal and multidisciplinary approach allows for accurate diagnosis, appropriate intervention, and safe decannulation. AS = aortic stenosis; CT = computed tomography; DES = drug-eluting stent; ECMO = extracorporeal membrane oxygenation; ECPR = extracorporeal cardiopulmonary resuscitation; EGD = esophagogastroduodenoscopy; LF-LG = low-flow, low-gradient; RCA = right coronary artery; STEMI = ST-segment elevation myocardial infarction; TAVI = transcatheter aortic valve implantation; TTE = transthoracic echocardiography; VA-ECMO = veno-arterial extracorporeal membrane oxygenation; VFib = ventricular fibrillation.

• 

  Figure 1. Resuscitative Transesophageal Echocardiogram 2-dimensional transesophageal echocardiogram midesophageal right ventricular inflow-outflow view (55°) obtained immediately following extracorporeal membrane oxygenation cannulation demonstrating severe aortic valve calcification.

• 

  Figure 2. Transthoracic Echocardiography of the Aortic Valve 2-dimensional transthoracic echocardiography parasternal long axis with a focus on the aortic valve demonstrating severe calcification of the leaflet tips and qualitative stenosis.

• 

  Figure 3. Transthoracic Echocardiography Continuous Wave Doppler Hospital Day 2 2-dimensional transthoracic echocardiography apical 5-chamber with continuous wave Doppler through the aortic valve demonstrating a peak velocity of 2.2 m/s, aortic valve area velocity time integral 25.9 cm, and calculated aortic valve area of 0.6 cm2.

• 

  Figure 4. Transthoracic Echocardiography Pulse Wave Doppler Hospital Day 2 2-dimensional transthoracic echocardiography apical 5-chamber with pulse wave Doppler through the left ventricular outflow tract demonstrating a velocity time integral of 6.2 cm.

• 

  Figure 5. Transthoracic Echocardiography Pulse Wave Doppler During Dobutamine Stress Echocardiogram, Hospital Day 3 2-dimensional transthoracic echocardiography apical 5-chamber with pulse wave Doppler through the left ventricular outflow tract demonstrating a velocity time integral of 10.4 cm.

• 

  Figure 6. Transthoracic Echocardiography Continuous Wave Doppler During Dobutamine Stress Echocardiogram, Hospital Day 3 2-dimensional transthoracic echocardiography apical 5-chamber with continuous wave Doppler through the aortic valve demonstrating a peak velocity of 3.08 m/s, aortic valve area velocity time integral 39.4 cm, and calculated aortic valve area of 0.71 cm2.

• 

  Figure 7. Echocardiographic Assessment of Suspected Severe AS on VA-ECMO An algorithm used in the echocardiographic assessment of suspected severe AS in patients on VA-ECMO. In patients suspected of LF-LG AS, a multimodal evaluation is recommended for accurate diagnosis. AS = aortic stenosis; AVA = aortic valve area; CT = computed tomography; EF = ejection fraction; LF-LG = low-flow, low-gradient; VA-ECMO = veno-arterial extracorporeal membrane oxygenation.

• 

  Figure 8. Weaning VA-ECMO with LF-LG Severe AS An algorithm used to differentiate responses to VA-ECMO weaning and guide appropriate therapy in patients with severe AS. HR = heart rate; LVOT = left ventricular outflow tract; MAP = mean arterial pressure; PADP = pulmonary artery diastolic pressure; PCWP = pulmonary capillary wedge pressure; RAP = right atrial pressure; SpO2 = peripheral oxygen saturation; other abbreviations ass in Figure 7.