Abstract:Indications for extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR) are expanding, and echocardiography is a tool of utmost importance to assess safety, effectiveness and readiness for circuit initiation and separation. Echocardiography is key to anticipating complications and improving outcomes. Understanding the patient's as well as the ECMO circuit's anatomy and physiology is crucial prior to any ECMO echocardiographic evaluation. It is also vital to acknowledg… Show more
“…Also, intracavitary thrombus formation and pulmonary oedema will occur when left atrial pressure exceeds 25–30 mm Hg. Echocardiography is essential in assessing LV distension and presence of spontaneous contrast (55). To provide optimal myocardial recovery, attempts should be made to prevent dilatation of the left side of the heart.…”
Worldwide, the use of Extracorporeal Membrane Oxygenation (ECMO) for cardiac failure has been steadily increasing in the neonatal population and has become a widely accepted modality. Especially in centers caring for children with (congenital) heart disease, ECMO is now an essential part of care available for those with severe heart failure as a bridge to recovery, long term mechanical support, or transplantation. Short-term outcomes depend very much on indication. Hospital survival is ~40% for all neonatal cardiac ECMO patients combined. ECMO is being used for pre- and/or post-operative stabilization in neonates with congenital heart disease and in neonates with medical heart disease such as myocarditis, cardiomyopathy or refractory arrhythmias. ECMO use during resuscitation (ECPR) or for sepsis is summarized elsewhere in this special edition of Frontiers in Pediatrics. In this review article, we will discuss the indications for neonatal cardiac ECMO, the difficult process of patients' selection and identifying the right timing to initiate ECMO, as well as outline pros and cons for peripheral vs. central cannulation. We will present predictors of mortality and, very importantly, predictors of survival: what can be done to improve the outcomes for your patients. Furthermore, an overview of current insights regarding supportive care in neonatal cardiac ECMO is given. Additionally, we will address issues specific to neonates with single ventricle physiology on ECMO, for example cannulation strategies and the influence of shunt type (Blalock-Taussig shunt vs. “right ventricle to pulmonary artery” shunt). We will not only focus on short term outcomes, such as hospital survival, but also on the importance of long-term neuro-developmental outcomes, and we will end this review with suggestions for future research.
“…Also, intracavitary thrombus formation and pulmonary oedema will occur when left atrial pressure exceeds 25–30 mm Hg. Echocardiography is essential in assessing LV distension and presence of spontaneous contrast (55). To provide optimal myocardial recovery, attempts should be made to prevent dilatation of the left side of the heart.…”
Worldwide, the use of Extracorporeal Membrane Oxygenation (ECMO) for cardiac failure has been steadily increasing in the neonatal population and has become a widely accepted modality. Especially in centers caring for children with (congenital) heart disease, ECMO is now an essential part of care available for those with severe heart failure as a bridge to recovery, long term mechanical support, or transplantation. Short-term outcomes depend very much on indication. Hospital survival is ~40% for all neonatal cardiac ECMO patients combined. ECMO is being used for pre- and/or post-operative stabilization in neonates with congenital heart disease and in neonates with medical heart disease such as myocarditis, cardiomyopathy or refractory arrhythmias. ECMO use during resuscitation (ECPR) or for sepsis is summarized elsewhere in this special edition of Frontiers in Pediatrics. In this review article, we will discuss the indications for neonatal cardiac ECMO, the difficult process of patients' selection and identifying the right timing to initiate ECMO, as well as outline pros and cons for peripheral vs. central cannulation. We will present predictors of mortality and, very importantly, predictors of survival: what can be done to improve the outcomes for your patients. Furthermore, an overview of current insights regarding supportive care in neonatal cardiac ECMO is given. Additionally, we will address issues specific to neonates with single ventricle physiology on ECMO, for example cannulation strategies and the influence of shunt type (Blalock-Taussig shunt vs. “right ventricle to pulmonary artery” shunt). We will not only focus on short term outcomes, such as hospital survival, but also on the importance of long-term neuro-developmental outcomes, and we will end this review with suggestions for future research.
“…Echocardiography is a valuable tool for excluding complications like pericardial tamponade, aortic regurgitation, cannula malposition, thrombus, and hypovolemia. 11 It has a role in everyday assessment of heart to predict the need of further mechanical support or the possibility of successful weaning from ECMO. In our study, we did baseline echocardiography evaluation after initial ECMO setup, followed by serial evaluations of heart every 12 hours during ECMO run.…”
Extracorporeal membrane oxygenation (ECMO) has emerged as an effective mechanical support device to support both respiratory and cardiac function following cardiac surgery. The use of ECMO is more common among children who undergo complex surgical procedures. The objective of this study was to observe the outcomes of children subjected to central venoarterial (VA) ECMO after congenital cardiac surgery and identify the factors influencing survival in these children. Twenty children, below the age of 1 year, who underwent corrective cardiac surgery and were placed on ECMO support within first 48 hours of biventricular repair, from July 2018 to June 2019, were included in this study. ECMO was initiated either in the operating room (either preoperative decision or unable to come off cardiopulmonary bypass [CPB]) or in the intensive care unit (low-cardiac output syndrome). The maintenance and weaning from ECMO was done as per institute protocol. At the initiation of ECMO, the flows were maintained between 100 and 150 mL/kg/min. The flows were decreased if it was possible to maintain normal perfusion with lesser flows. Out of 20 children, 12 children were less than or equal to 2 months of age. The 30-day survival was 45% and all the children were alive at 4 months after discharge from hospital. A negative cumulative fluid balance (CFB) of more than 50 mL/kg in the first 48 hours, decreasing lactate and inotropic score, and improving ventricular function in the first 3 days of ECMO were associated with improved survival. The following factors were correlated with decreased survival: aortic cross-clamp time (AOCX T) more than 106 minutes, higher initial ECMO flows (75 vs. 52%), ECMO duration more than 4 days, increased transfusion of blood and blood products, urine output < 1.06 ± 0.81/kg/h (in the first 48 h), and increasing trend of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).
“…The decision to vent the heart is based on TTE findings. TTE assists in documenting serial ventricular function improvement, identifying pericardial/pleural effusions, assessing pulmonary hypertension and shunting at atrial or ventricular levels [ 83 ]. All inotropes are stopped when complete myocardial rest is indicated.…”
Section: Discussionmentioning
confidence: 99%
“…If the trial period off ECMO is uneventful, the patient is decannulated [ 89 ]. TTE plays a pivotal role during various stages of weaning and in the post-wean phase [ 83 ]. Fig.…”
The ultimate goals of cardiovascular physiology are to ensure adequate end-organ perfusion to satisfy the local metabolic demand, to maintain homeostasis and achieve ‘milieu intérieur’. Cardiogenic shock is a state of pump failure which results in tissue hypoperfusion and its associated complications. There are a wide variety of causes which lead to this deranged physiology, and one such important and common scenario is the post-cardiotomy state which is encountered in cardiac surgical units. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an important modality of managing post-cardiotomy cardiogenic shock with variable outcomes which would otherwise be universally fatal. VA-ECMO is considered as a double-edged sword with the advantages of luxurious perfusion while providing an avenue for the failing heart to recover, but with the problems of anticoagulation, inflammatory and adverse systemic effects. Optimal outcomes after VA-ECMO are heavily reliant on a multitude of factors and require a multi-disciplinary team to handle them. This article aims to provide an insight into the pathophysiology of VA-ECMO, cannulation techniques, commonly encountered problems, monitoring, weaning strategies and ethical considerations along with a literature review of current evidence-based practices.
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