REVIEW ARTICLE |
https://doi.org/10.5005/jp-journals-10089-0090 |
The Role of Echocardiography in Extracorporeal Membrane Oxygenation
1,2Department of AITU, Narayana Institute of Cardiac Sciences, Bommasandra, Narayana Health, Bengaluru, Karnataka, India
Corresponding Author: Sunil Kumar V, Department of AITU, Narayana Institute of Cardiac Sciences, Bommasandra, Narayana Health, Bengaluru, Karnataka, India, Phone: +91 9731522994, e-mail: sunilanaesthesia14@gmail.com
Received: 18 May 2023; Accepted: 24 July 2023; Published on: 19 February 2024
ABSTRACT
Echocardiography (ECHO) is an essential diagnostic tool for patients who require extracorporeal membrane oxygenation (ECMO). ECMO provides oxygenation and circulatory support to patients with severe cardiac/respiratory dysfunction. ECHO plays an important role in the management and evaluation of ECMO therapy. ECHO is a relatively noninvasive imaging technique that uses high-frequency sound waves to produce detailed imaging of the heart’s structure and functionality. It is used to evaluate various aspects of cardiac function, including cardiac output, ejection fraction (EF), regional wall motion abnormalities (RWMA), and valvular function. ECHO provides vital information about the cardiopulmonary physiological response to ECMO therapy. Apart from helping identify intra and extracardiac thrombi and clots, it is used for the assessment of ECMO cannula placement to optimize blood flow mechanics and gas exchange. One of the advantages of ECHO in ECMO support is its versatility in providing real-time feedback that enables clinicians to optimize therapy and mitigate potential complications during the ECMO run. ECHO helps diagnose and quantify conditions that cause hemodynamic instability, such as undiagnosed valvular lesions, ventricular dysfunction, and aortic dissection. Epiaortic ECHO provides information about aortic atheroma and aids in selecting the best site for aortic cannulation. The placement of venous cannula for venovenous (VV)—ECMO or venoarterial (VA)—ECMO can be affected by anatomical abnormalities of the heart such as left-sided superior vena cava (SVC), Chiari network, prominent eustachian valve, atrial septal defect (ASD) all of which can be diagnosed by ECHO.
How to cite this article: Sunil Kumar V, Orathi Patangi S. The Role of Echocardiography in Extracorporeal Membrane Oxygenation. J Acute Care 2023;2(3):153–157.
Source of support: Nil
Conflict of interest: None
Keywords: Atherosclerotic, Cannula, Catheterization, Extracorporeal membrane oxygenation, Humans, Plaque, Stroke volume, Thrombosis, Vascular diseases, Vena cava
Extracorporeal membrane oxygenation (ECMO) is an advanced form of mechanical support that provides oxygenation and circulatory assistance to patients with severe cardiac/respiratory dysfunction. Echocardiography (ECHO) is an essential tool for patients who require (ECMO) as it plays an important role in the initiation, management, evaluation, and weaning of ECMO therapy.1–4 ECHO is a relatively noninvasive imaging technique that uses high-frequency sound waves to produce detailed imaging of the heart’s morphology and function. It is used to evaluate various aspects of cardiac function, including regional wall motion abnormalities (RWMA), valvular function, cardiac output, and ejection fraction (EF). ECHO provides vital information about the cardiopulmonary physiological response to ECMO therapy.5 Apart from assessment for ECMO cannula placement6 and optimization of blood flow mechanics and gas exchange, ECHO is helpful in identifying intra and extracardiac thrombi, clots, and other complications. One of the advantages of ECHO in ECMO support is its versatility to provide real-time feedback that enables clinicians to optimize therapy and mitigate potential complications during the ECMO run.7,8
Echocardiography (ECHO) helps diagnose and quantify conditions that cause hemodynamic instability, such as undiagnosed valvular lesions, ventricular dysfunction, and aortic dissection. Epiaortic ECHO provides information about aortic atheroma and aids in selecting the best site for aortic cannulation.9 The placement of venous cannula for venovenous (VV)—ECMO or venoarterial (VA)—ECMO can be affected by anatomical abnormalities of the heart such as left-sided superior vena cava (SVC), Chiari network, prominent eustachian valve, atrial septal defect (ASD) all of which can be diagnosed by ECHO (Table 1).10
| VV-ECMO | |
|---|---|
| Indications | Contraindications |
| Hypoxemic respiratory failure (PaO2a/FiO2b <80 mm HG), after optimal medical management | Significant central nervous system (CNS) injury |
| Hypercapnic respiratory failure (pH of <7.25) after optimal mechanical ventilation | Irreversible and incapacitating CNS pathology |
| Bridge to lung transplant | Systemic bleeding, contraindication to anticoagulation |
| Immunosuppression, older age | |
| Mechanical ventilation for >7 days with Pplatc > 30 cm H2O and FiO2 > 90% | |
| Acute myocardial infarction | Cardiogenic shock of >6 hours |
| Myocarditis | Advanced carcinoma |
| Overdose of cardiotoxic drugs | Advanced liver disease |
| Cardiomyopathy | Acute brain injury |
| Pulmonary embolism | Vascular disease |
| Postcardiotomy cardiogenic shock | Immunocompromised state |
aPartial pressure of oxygen; bfraction of inspired oxygen; cplateau pressure
ROLE OF ECHOCARDIOGRAPHY FOR VV-ECMO CANNULATION/INITIATION
Peripheral VV-ECMO is placed percutaneously or via a surgical cutdown. Several configurations are possible. The drainage cannula is inserted into the femoral vein in the femoral-jugular arrangement and advanced to the level of the diaphragm above the hepatic veins.4 The return cannula is inserted via the internal jugular vein (IJV) and sited at the level of the SVC-right atrium (RA) junction (Fig. 1). Recirculation is a condition where some of the returning oxygenated blood is inadvertently sucked back into the ECMO circuit, and inadequately oxygenated blood traverses the pulmonary and systemic circulation.12 A separation distance of approximately 15 cm between the cannulae prevents recirculation in an adult patient.13 Femoro-femoral VV-ECMO refers to a setup where the drainage and return cannulas are inserted through the femoral veins. The drainage cannula and the return cannula are positioned on bilateral femoral veins in this arrangement.12 ECHO is useful for verifying guide wire placement and ascertaining the final position of the cannulae. The midesophageal bicaval (BC) view (Fig. 2) with transesophageal ECHO (TOE) helps ascertain the ideal position for the venous cannulae. The location of the guide wires in the SVC and inferior vena cava (IVC) must be seen in real-time using the BC view on TOE (Fig. 2).4 This is done to prevent the cannula from being improperly positioned in the right ventricle (RV), coronary sinus, or even worse, in the left atrium (LA) via a patent foramen ovale or ASD (Fig. 3).5,7,10 An adequately positioned IVC cannula can be visualized by advancing the TOE probe downward from the BC view without changing the array angle (Fig. 4).
Fig. 1: Placement of SVC and IVC cannula where blue arrows show drainage of venous blood from IVC to red arrows showing returning the arterial blood into the RA and toward the tricuspid valve
Fig. 2: Midesophageal bicaval (BC) view in transesophageal view to visualize SVC, IVC, RA, and LA
Fig. 3: Midesophageal bicaval (BC) view in TOE showing the ASD to be identified before initiating ECMO
Fig. 4: Transesophageal ECHO (TOE) showing IVC drainage cannula
Dual Lumen Cannula
A dual lumen cannula allows VV-ECMO initiation with a single cannula inserted in the right IJV (Fig. 5). This enhances patient mobility, and neck cannulation carries a lower infection risk compared to groin cannulation. The placement of a dual-lumen cannula carries a risk of vascular damage and consequent cardiac tamponade secondary to the cannula’s stiffer and larger diameter. Cannula migration from its initial site is a known complication that can be easily diagnosed by ECHO.14During insertion, the cannula’s tip is advanced under ECHO and fluoroscopic guidance until the drainage holes are positioned in the SVC-IVC confluence, and the return lumen is in line with the tricuspid valve. Color flow Doppler is used to ascertain this alignment, which will reveal a linear flow in the event of proper positioning and a turbulent flow in the case of incorrect positioning.15 Visualizing the cannula tip in relation to the hepatic vein requires special attention as it is imperative that the hepatic vein is not occluded.
Fig. 5: Dual lumen cannula showing blue arrows showing drainage of venous blood from the RA and red arrows showing return arterial blood toward the tricuspid valve
ROLE OF ECHOCARDIOGRAPHY FOR VA-ECMO INITIATION
Echocardiography (ECHO) and vascular ultrasonography are useful tools for initiating and monitoring an ECMO run. VA-ECMO can be initiated centrally or peripherally.16 ECHO is a useful tool to outline the guide wire placement in initiating both forms of ECMO. The placement of a left ventricle (LV) vent to aid decompression of the LV should be considered if the LV is not fully decompressed.17 LV venting is crucial to adequately rest the heart whilst on VA ECMO (Fig. 6). ECHO helps identify the position of the LV vent and look for thrombus formation. Flows via the LV vent can be monitored with ECHO using a continuous wave doppler angled through the LV vent. Serially increasing velocities are diagnostic of an obstruction in the LV vent. LV venting strategies are associated with a 35% higher probability of weaning and a 12% lower risk of mortality.18 Other modalities of LV venting, such as balloon atrial septostomy, usage of an intraaortic balloon pump, pulmonary artery (PA) venting, and usage of an Impella device as an LV vent can be monitored using ECHO.19,20
Fig. 6: Transgastric view showing blood flow across the left ventricular vent using TOE
Echocardiography (ECHO) is diagnostic to detect inadvertent aortic dissection or aortic valve (AV) damage manifesting as severe aortic regurgitation (AR) (Fig. 7). When percutaneous RV support with an oxygenator in the circuit is being considered, ECHO is a helpful tool to allow for adequate positioning of the device in the RA and the main PA.21
Fig. 7: Midesophageal AV long axis showing type ”A” aortic dissection with severe aortic regurgitation (AR) in TTE which is contraindication for ECMO
ROLE OF ECHO IN ECMO MAINTENANCE
VA-ECMO
Serial ECHO cardiograms are useful for monitoring cardiac chamber size and AV opening. ECHO is used to identify pericardial and pleural collections (Figs 8 and 9), which are common occurrences of ECMO.19 Low flow alarms, suck down of the cannulae in situ, cannulae migration, and thrombotic occurrences on the cannulae are identified using ECHO.20,22 Maintaining the flow rate on ECMO is essential. Reduced flow may be brought on by blockages (thrombus), improper cannula positioning, or hypovolemia, all of which are diagnosed using ECHO.4,13
Fig. 8: Transthoracic ECHO (TTE) showing pericardial effusion in the subcostal view
Fig. 9: Transthoracic ECHO (TTE) showing plural effusion with septation
VV-ECMO
Echocardiography (ECHO) assists the clinician in determining the cause of inadequate flows during an ECMO run. Volume overload status and, conversely, IVC collapse around the IVC cannula diagnosed on ECHO prompts alteration of fluid management.13 Reduced ECMO flows can be caused by cannula displacement that could result in significant hypoxemia.19 ECHO is a useful tool to ascertain the appropriate cannula position.
ROLE OF ECHO IN DETECTING COMPLICATIONS ON ECMO
Extracorporeal membrane oxygenation (ECMO) therapy is associated with complications. Common complications are bleeding, thromboembolic events, sepsis, and collections. Limb ischemia, hemolysis, and mechanical failure (such as oxygenator or cannula or device thrombosis) are less common issues. Intracerebral hemorrhage, circuit rupture, inadvertent decannulation, and air embolism are all rare but potentially fatal consequences, a majority of which are diagnosed using ECHO.4
ROLE OF ECHO IN WEANING
Echocardiography (ECHO) plays a pivotal role during ECMO weaning and involves a graded reduction of mechanical support. ECHO helps the clinician assess cardiovascular function serially, ensuring a smooth transition from mechanical support to native circulation.
Echocardiography in Weaning of VV-ECMO
Assessment of RV function using ECHO is crucial for reducing complications and enhancing outcomes in patients initiated on VV-ECMO for treating adult respiratory response syndrome (ARDS).5,8,14 ARDS causes right heart strain. The improvement of the disease process can be monitored with a reduction of RV strain patterns and RV size assessment.8,10 Four chamber view, parasternal long axis view, and parasternal short axis view in transthoracic ECHO (TTE) are useful to assess RV function. Reduced RV size, improved RV EF, improved RV fractional area change, and improved RV strain are all signs of improved RV function. Transannular plane systolic exertion (TAPSE) and tricuspid regurgitation measurements do not correlate well with RV function assessment in VV-ECMO.19
Echocardiography in Weaning VA-ECMO
Venoarterial (VA)—ECMO flows are reduced in a graded fashion, and ECHO parameters are serially assessed after the heart is loaded with vasoactive support (Ramp test). Once the patient passes the Ramp test, they could be considered for an attempt to wean off VA-ECMO. The left ventricular outflow tract velocity time integral (LVOTVTI) >10 cm (Fig. 10), (TAPSE) >13 (Fig. 11), the absence of RWMA, significant pericardial effusion, improved EF and most importantly an increase of the lateral mitral annulus peak systolic velocity (S’ wave); a TDI of >6 cm/s (Fig. 12), are ECHO data that suggest a possibility of a successful wean from VA-ECMO.23,24 Concomitant monitoring of vital signs, arterial and venous blood gases, and close monitoring of lactate levels are recommended practices in conjunction with ECHO monitoring to aid successful weaning.24,25
Fig. 10: Transthoracic ECHO (TTE) showing LVOTVTI
Fig. 11: Transannular plane systolic exertion (TAPSE)
Fig. 12: Lateral mitral annulus peak systolic velocity (S’)
CONCLUSION
Echocardiography (ECHO) is a valuable diagnostic tool for patients requiring ECMO support. Its relatively noninvasive nature facilitates real-time vital feedback during ECMO therapy and enables clinicians to monitor cardiac functionality, preempt complications, and titrate ECMO support. ECHO can be deemed a fundamental requirement to monitor and manage ECMO therapy.
ORCID
Sunil Kumar https://orcid.org/0000-0002-6689-1294
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