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** VA-ECMO Hemodynamics Illustrative Example **
59-year-old male with presents with cardiogenic shock from a STEMI resulting in a large ventricular septal rupture (VSR) (2.6 cm) with left to right shunting.
https://www.cjcopen.ca/article/S2589-790X(20)30095-0/fulltext
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59-year-old male with presents with cardiogenic shock from a STEMI resulting in a large ventricular septal rupture (VSR) (2.6 cm) with left to right shunting.
https://www.cjcopen.ca/article/S2589-790X(20)30095-0/fulltext
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A VSR reduces LV afterload, as blood is shunted to the RV (low pressure) instead of through the aortic valve (high pressure). The treatment is mechanical support and vasodilators as a bridge to surgery.
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VA-ECMO pumps oxygenated blood retrograde in the aorta. Unfortunately, it increases LV afterload and LVEDP. LV unloading with MCS (IABP here) and vasodilators reduces afterload to promote LV ejection through the aortic valve.
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As VA-ECMO flows increases to 5.5 L/min, the LV afterload overwhelms the ability of the LV to eject through the aortic valve. Static blood will appear as echo contrast, then sludge, then thrombus. This is devastating.
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We quickly turn down the ECMO flow to 4.5 L/min to allow LV ejection, aortic valve opening, and immediate clearance of aortic sludge.
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This illustrative example demonstrates the unique hemodynamics of VA ECMO and VSR. It highlights the importance of ECMO ramp studies and careful monitoring. The pulse pressure is a good surrogate for AV opening.
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How would you approach this situation?
@RaynerHartleyMD @Thind888 @msiuba @Wormsy10 @FH_Verbrugge @ThinkingCC @fpmorcerf @AndrewJSauer @Wormsy10 @YasMoayedi @NephroGuy @NephroP @oscaar84 @FilioBillia @Doctor_Darshan @HeartDocSharon
@RaynerHartleyMD @Thind888 @msiuba @Wormsy10 @FH_Verbrugge @ThinkingCC @fpmorcerf @AndrewJSauer @Wormsy10 @YasMoayedi @NephroGuy @NephroP @oscaar84 @FilioBillia @Doctor_Darshan @HeartDocSharon
