POCUS & VA ECMO

POCUS & VA ECMO

Hey everyone!

Here is another great case, using POCUS transthoracic echo in caring for a patient on VA ECMO.

Stem: Patient transferred from outside facility on VA ECMO for massive PE. Clips are labeled at 4.5 LPM, 2.5 LPM and 1 LPM flows.

• Based on these clips, how do you interpret these findings?
• What is the LV systolic function? What about the RV?
• Does this patient look ready to wean from VA ECMO support?

Please share your thoughts! It is ok to be wrong- this is meant to be a safe space for learning and applying POCUS. I will post further thoughts/ interpretations of the case next week!

-Christopher

Tags: 
POCUS, VA ECMO, weaning, Pulmonary Embolism

 

Comments (3)

karthik vadamalai
says:

LV systolic and RV systolic function is severely decreased. At 4.5L flow of VA ECMO - the PLAX shows decreased LV function, presence of aortic regurgitation; PSAX- akinetic posterior and inferior left ventricular walls. At 2.5L and 1L flow, there is dilation of the LV and RV chamber on PSAX views. Also, the RSVP seems to be increasing as indicated by the increase in TR jet velocity. this can point to failing RV as we decrease VA ECMO flow. Overall the POCUS images are NOT supporting readiness of weaning off of VA ECMO at this point. Further hemodynamic parameters (CVP, MAP, PA pressure ) would be needed to make the decision about weaning from ECMO

Ben Smith
says:

Images likely taken as part of a VA ECMO weaning trial. PLAX views appear to show severely reduced LV function with small amount of MR. I think the PSSX view at 4.5 LPM is the "wrap around" view taken at the level of the aortic valve, with tricuspid valve to the left and right PA below it, so difficult to compare it to the PSSX views done at lower flows since they're at the papillary muscle level. In Ap4 views, RV looks like it has reduced function. In the PSSX views, there appears to be progressively more septal bowing as flows decrease, suggesting worsening RV overload. However, LV in these views looks like it may have progressively better contractility with decreased flows, possibly from working against less afterload or a more manageable preload (thanks to failing RV). The drop in flows results in a slightly higher velocity TR jet, though going from 1.95m/s to 2.0m/s only results in <5mmHg difference in RVSP, which is a little discordant with the rest of the picture. Unable to say whether this patient appropriate to wean without a lot more clinical info, though based on the RV appearing to distend at lower flows, I would think no.

Hey everyone,

Here are thoughts on this case/ "answers" from one of our POCUS experts and CTICU attendings (TK):

Overall there is severely depressed BiV function at full ECMO flows with modest improvement in LV contractility with weaning of flows. At 1 LPM there is worsening septal flattening noted throughout the cardiac cycle that is more pronounced during diastole, consistent with right sided volume overload and acute cor pulmonale. RVSP (RV inflow) was not significantly changed at full vs reduced ECMO flows, again consistent with acute right heart failure. Limited views of the RVOT and pulmonary trunk showed no clot in transit (thought the RPA was incompletely visualized).

Miscellaneous findings: trace MR, mild TR that qualitatively worsened with weaning of ECMO flows, venous drainage cannula in acceptable position at the IVC-RA junction. Trace pericardial effusion.

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