VenoArterila ECMO - 006.pptx

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a temporary, mechanical, circulatory, and respiratory support system. Its main use is in patients with heart and/or respiratory failure, allowing complete support by ensuring continuous systemic perfusion and oxygenation.

1. VA-ECMO Veno-Arterial Extracoporeal Oxygenation Name : Yukta Wankhede PRN : 21040143006 Programme : M.Sc MT Cardiac Care Technology Subject : Periphreal Catheterization

2. Introduction Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a temporary, mechanical, circulatory, and respiratory support system. Its main use is in patients with heart and/or respiratory failure, allowing complete support by ensuring continuous systemic perfusion and oxygenation. This support system has traditionally been used as “rescue” therapy in patients with cardiogenic shock. However, ECMO implantation in emergency conditions is burdened by relevant mortality and morbidity, due to high vascular complications and reduced coronary reserve of patients with severe aortic stenosis or complex coronary artery disease, especially in the presence of a reduction of the global systolic function. In these cases, prolonged hypotension can lead to a rapid deterioration of hemodynamic conditions with the development of cardio-metabolic shock. Recently, the use of ECMO as support during percutaneous complex cardiac interventions has been proposed, especially in high-risk patients. Besides the clinical aspects, also some technical issues have to be taken into account, such as complex anatomies with an extensive ischemic area at risk and severe impaired ventricular systolic function.

3. Indications Reduced left ventricular ejection fraction. Patients with depressed ventricular function and aortic stenosis Severe coronary artery disease (usually involving the left main or equivalent) in patients with severe chronic respiratory failure, even with normal left ventricular function. In lung transplant list for severe and extensive pulmonary fibrosis after COVID-19 pneumonia, suffering from a 90% stenosis of the distal left main coronary artery, involving the ostia of the anterior descending artery and circumflex and had an intermediate branch of large calibre and distribution occluded, in a left-dominated coronary circle. Combined valve disorders in patients with severe left ventricular impairment [TAVI and Mitraclip (Abbott)]. Severe coronary artery disease (“high-risk PCI”) in patients who cannot receive other assistance systems [Impella]. In prophylactic action aimed at hemodynamic stability during the procedure, the assistance can also be used to facilitate the technical development of the procedure [Triclip, Abbott].

4. Complications Irreversible primary disease CNS injury Lung injury for > 3 weeks Risk of pulmonary fibrosis COPD Unwitnessed cardiac arrest Active hemorrhage Active infection Multiple organ failure Terminal cancer Advanced age

5. VA ECMO Therapy VA ECMO is utilized in patients with cardiac failure. A catheter takes blood from a major vein, is pumped through the ECMO machine, and returned to the arterial circulation via a major artery. The heart functions partially. Ex. If patient required total CO=5L/min and pump flow=3L/min, then patient’s heart is ejecting about 2L/min.

6. VA ECMO Configurations Central cannulation Right atrium or Femoral Vein ------ ECMO -------- Ascending Aorta Often following an open-heart procedure where heart is already cannulated and patient is not able to come off from CPB. (post-cardiogenic shock) Peripheral cannulation Either percutaneous or open cut-down Percutaneous often done at bedside vs operating room for open cut-down Femoral vein or Right IJ -------- ECMO --------- Femoral, Innominate, or Axillary Artery

7. VA ECMO

8. VA Fem-Fem Peripheral Cannulation Percutaneous Femoral Accesses for ECMO (A) and Coronary Angioplasty (B).

9. VA- ECMO Transport Circuit

10. ECMO Configuration Cannula Insertion Sites and Position : Femoral vessels, aorta, right atrium, Internal jugular vein, Subclavian and Axillary vessels Incision Type : Percutaneous, open cut-down, tunneling Cannula Type : Single vs multi-stage, single vs dual lumen Tip Position : Right atrium, tube graft sewn to artery, antegrade vs retrograde direction Size: Access Venous cannulas are generally larger lumen (22-28Fr) to allow better drainage and longer (50-55cm) Return cannulas are smaller (16-20fr) and shorter (15-25cm) Distal limb cannula (8-10fr)

11. ECMO Cannulas & Equipment Single Lumen Cannulas **Cannula selection is patient specific. Larger patients requiring higher flows warrant cannulas with larger lumen or French size (Fr) **1 mm=3 Fr**

12. Cannula Insertion Kits & Dilators

13. ECMO Equipment

14. ECMO Initiation Notify physician and ECMO Specialist (ES) immediately if ECMO therapy is warranted. Low sustained MAP from hypokinetic heart; Max inotropic/vasoactive support Low arterial saturations from unresponsive lungs; Max vent settings Equipment and Surgical field supplies for OR, cath lab, or bedside initiation ECMO circuit w/ attached heater/cooler setup by the ES Cut-down vascular tray, 4 Sterile tubing clamps, cannulas, insertion kits w/ guide wires, cannula stitches, ultrasound machine for locating vessel, heparin, 1L NS with turkey bulb syringe,

15. ECMO Initiation Physician chooses ECMO mode and begins to locate blood vessels for cannulation. Patient must be heparinized prior to insertion of cannulas Due to the continuous circulation of blood through a foreign surface (ECMO), anticoagulation therapy is warranted. The oxygenator is the primary component of circuit that is prone to clots. Heparin bolus of units/kg and maintenance drip started at 500 units/hr Target anticoagulation levels: Partial Thromboplastin Times (PTT) Activated Clotting Time (ACT) secs Dosing protocol is also dependent on patient’s current hemostasis (bleeding, coagulation, TEG) Alternative Anticoagulants: Angiomax, Argatroban

16. ECMO Initiation The ES assist physician with cannula selection and flow requirements Physician inserts cannulas and connects it to ECMO circuit tubing ECMO Specialist performs pre-bypass checklist and confirms with physician before initiating ECMO therapy. Therapeutic flow and gases are confirmed with physician. Physician secures the cannulas & tubing to the patient with stitches while the ES tie-bands all tubing connections.

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