Professional Documents
Culture Documents
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
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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