VA ECMO

For the Cardiology Fellows

Jenelle Badulak, MD

Emergency Medicine & Critical Care Medicine

badulakj@uw.edu

Learning Objectives

1. VA patient selection
2. VA hemodynamic management
3. LV unloading
4. VA dual circulations and gas exchange
5. VA weaning

Meet Sandy  

Vol Control

Vt 8cc/kg

RR 30

FiO2 40%

PEEP 5

SpO₂ 98%

55 F with palpitations for “a while”, hypotensive, rapid Afib, cool extremities

Intubated, DCCV, amiodarone, persistently hypotensive, end organ dysfunction

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VA ECMO candidate?

CVP 18

RV 36/17

PA 35/25(28)

Wedge 24

SvO₂ 35%

CI 1.3(thermo)

BP 81/62(72)

0.3 mcg/kg/min

10 mcg/kg/min

0.08 mcg/kg/min

SCAI Classification: Cardiogenic Shock

Society for Cardiovascular Angiography and Interventions (SCAI), mechanical circulatory support (MCS)

PMID: 31104355

E

Extremis: circulatory collapse, near pulseless or CPR

Beginning: soft BP/tachycardia, perfusing, warm no vasoactives

At risk: myocardial infarction, heart failure symptoms

D

C

B

A

Deteriorating: class “C” failed to respond after 30min, escalating vasoactives

Classic: usually hypotensive, cool, hypoperfusion, vasoactives +/- MCS

Cardiac Power Index

CPI = MAP x CI

451

66 x 1.3 / 451 = 0.19

PAC: CVP 18, PA 35/25(28), SvO₂ 35%, CI 1.3 (thermo), 1.7 (Fick)

Echocardiogram

(+/- PAC)

Moderate ventricular dysfunction

(CPI > 0.32)

Small Impella or IABP

Severe ventricular dysfunction

(CPI < 0.32)

1^○ LV dysfunction

(PAPI > 1)

Big Impella, Tandem or

VA ECMO

Bi-V or RV dysfunction

(PAPI ≤ 1)

VA ECMO

PA Pulsatility Index

PAPI = PA syst – PA dias

CVP

35-25 / 18 = 0.56

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CANNULATION

• Cannula size?
• 25 Fr drainage, 17 Fr return
• Initial flow?
• Flow index 2.0-2.4 (depends on native heart function)
• 1.89 x 2.4 = 4.5 L/min

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Patient Stats:

• 172 cm height
• 76 kg
• BSA 1.89

INITIATION

B – Intervention

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A – Air free connection

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S – Set Sweep

T – Set Temperature

A – Anticoagulation

R – RPMs to 2000

When to stop CPR (if arrest)?

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Initial sweep?

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Post initiation tasks?

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VA Day 1

Sandy is cannulated for VA ECMO

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Hemodynamic strategy?

0.3 mcg/kg/min

10 mcg/kg/min

0.08 mcg/kg/min

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MAP

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Q

CVP

SVR

=

(

)

+

x

+

MAP: mean arterial pressure

Q: flow

SVR: systemic vascular resistance

CVP: central venous pressure

VA ECMO Hemodynamics

Flow then press!

Post-ML

pH: 7.23

P_aCO₂: 40

P_aO₂: 423

 HCO₃: 12

S_aO₂: 100%

Vent: VC, Vt 8cc/kg, RR 10, FiO2 40% PEEP 5, Ppeak 25, Pplat 15

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Post cannulation ventilator settings?

RUE

pH: 7.25

P_aCO₂: 44

P_aO₂: 310

 HCO₃: 12

S_aO₂: 100%

VA DAY 1

A few hours post cannulation…

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• Norepinephrine 0.1 mcg/kg/min
• Epinephrine 0.08 mcg/kg/min
• Dobutamine 10 mcg/kg/min

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PA pressure 35/25(28) 🡪 42/35(37)

CVP 18 🡪 24

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Copious pink frothy sputum from endotracheal tube

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LV EJECTION

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• Norepinephrine 0.09 mcg/kg/min
• Epinephrine 0.06 mcg/kg/min
• Dobutamine 8 mcg/kg/min

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When to place Impella or IABP?

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• Often needs vent = Chronic heart failure (dilated LV)
• Rarely needs vent = Acute reversible insult (hypothermia, MI, overdose)
• Indications:
• Refractory VF or pulseless VT

OR

• Pulse pressure <10, PA diastolic >25 + pulm edema, AoV not opening, echo smoke

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Impella placed🡪

-CVP & PAD decrease

-pulm edema better

-LV decompressed on echo

VA DAY 1

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What setting for the Impella?

• >P2, ideally 1-2 L/min, decrease if suction

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Next steps?

VA DAY 1

Distal perfusion catheter:

• Timing?

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• Unsure of position?

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• Adequacy of flow to leg?

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VA DAY 2

• Norepinephrine 0.05 mcg/kg/min
• Dobutamine 5 mcg/kg/min
• Epinephrine 0.08 mcg/kg/min
• Impella CP P4 (1.7 L/min)

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You notice a change on telemetry…

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What should you do next?

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VA Day 4

• LVEF now 20% (was 10%)
• Impella CP P4 (1.7 L/min)
• Ventilator starts alarming with increased peak pressure on volume control

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How do you troubleshoot this?

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0.04 mcg/kg/min

3 mcg/kg/min

VA DAY 3

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CXR

Mixing

point

Lung zone

ECMO zone

Two circulations in parallel🡪 two gas exchange zones

Titrate sweep to post membrane gas

Titrate vent to RUE gas

Upper body hypoxemia

Regional gas exchange 🡪 differential oxygenation

Keep pulse oximeter on right upper extremity!

Coronary hypoxemia

HYPOXEMIA ON VA ECMO

Differential Hypoxemia

Oxygenator Failure

Hypoxemia

Fix lungs?

Convert to VAV

Continue VA

Decannulate

Convert to VV

yes

no

Bad heart

Recovered heart

VA DAY 4

Chest percussion and suctioning with resolution of mucous plug and resolution of RUE hypoxemia!

VA DAY 7

Sandy feels way, way better. And she’s doing well extubated

LVEF of 35%, Dobutamine 5 mcg/kg/min, Impella CP P3

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What does this mean?

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What does it look like to wean VA vs VV?

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How do you decannulate?

VA WEANING

Wean ECLS Flow q5-15 min

(75%, 50%, 25%)

Minimum 1 L/min

Echo:

• LVEF > 25%
• Absence of worsening LV/RV distention, dysfunction or MR/TR

Hemodynamics:

• MAP > 65 mm Hg
• CVP not high
• Less than medium-dose vasoactive support

Monitor Oxygenation RUE:

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• SpO₂ > 90% with FiO₂ <60%, PEEP ≤10

Passed?

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Return to ≥ 50% flow 🡪 decannulation

*In OR: can place TEE, recirculate circuit with cannulas clamped to evaluate 0 L/min

SANDY IS ALIVE!!!

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Successfully decannulated!

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badulakj@uw.edu

www.corecmo.com