Hemodynamics of cardiac tamponade during extracorporeal membrane oxygenation support in a patient with fulminant myocarditis

Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation

Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.

Cardiac Tamponade Complicating Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis

OBJECTIVES

Cardiac tamponade is a potentially life-threatening complication during extracorporeal membrane oxygenation (ECMO). In this study, the authors assessed the incidence, patient characteristics, and risk factors for mortality of cardiac tamponade during ECMO.

DESIGN

The authors queried the Extracorporeal Life Support Organization (ELSO) Registry from 1997 to 2021 for all adults with cardiac tamponade as a reported complication during ECMO.

PARTICIPANTS

Cardiac tamponade was reported in 2,176 (64% men; 53.8 ± 0.33 years) of 84,430 adults (2.6%).

MEASUREMENTS AND MAIN RESULTS

Venoarterial ECMO was the main configuration (78%), followed by venovenous ECMO (VV ECMO) (18%), for cardiac (67%), pulmonary (21%) support, and extracorporeal cardiopulmonary resuscitation (ECPR) (12%). Percutaneous cannulation was performed in 51%, with the femoral vein and femoral artery as the most common sites for drainage and return cannulae, with dual-lumen cannulae in 39% of VV ECMO. Hospital survival was lower (35% v 49%; p < 0.01) when compared with that of all adults from the ELSO Registry. In multivariate analysis, age, aortic dissection and/or rupture, COVID-19, ECPR, pre-ECMO renal-replacement therapy, and prone position are associated with hospital mortality, whereas ECMO for pulmonary support is associated with hospital survival. Similarly, renal, cardiovascular, metabolic, neurologic, and pulmonary complications occurred more frequently in nonsurvivors.

CONCLUSIONS

Cardiac tamponade is a rare complication during ECMO that, despite being potentially reversible, is associated with high hospital mortality. Venoarterial ECMO is the most common configuration. ECMO for pulmonary support was associated with higher survival, and ECPR was associated with higher mortality. In these patients, other ECMO-related complications were frequently reported and associated with hospital mortality.

Peripheral VA-ECMO and pericardial drainage connected to the ECMO circuit for cardiac tamponade from blowout rupture: a case report

BACKGROUND

Left ventricular free wall rupture, particularly the blowout type, is still one of the most lethal complications of myocardial infarction and can cause catastrophic cardiac tamponade. Extracorporeal membrane oxygenation (ECMO) is often used to treat haemodynamic instability due to cardiac tamponade. However, elevated pericardial pressure can cause collapse of the right atrium, resulting in inadequate ECMO inflow and preventing the stabilisation of the circulation. Further, it can interfere with the venous return from the superior vena cava (SVC), increasing the intracranial pressure and reducing cerebral perfusion levels.

CASE PRESENTATION

A 65-year-old man was hospitalised for out-of-hospital cardiac arrest. We used ECMO for cardiopulmonary resuscitation. After the establishment of ECMO, transthoracic echocardiography and left ventriculography revealed massive pericardial effusion. The treatment was supplemented with pericardial drainage since ECMO flow was frequently hampered by suction events. However, the blowout rupture led to the requirement of constant drainage from the pericardial catheter. To tend to this leak, we connected the venous cannula of ECMO and the pericardial drainage catheter. The surgery was performed with stable circulation without suction failure of ECMO. During the course of the intensive care management, the neurological prognosis of the patient was revealed to be poor, and the patient was shifted to palliative care. Unfortunately, the patient died on day 10 of hospitalisation.

CONCLUSION

We present a case wherein the combination of pericardial drainage and ECMO was used to maintain circulation in a patient with massive pericardial effusion due to cardiac rupture.

Cardiac tamponade during venoarterial extracorporeal membrane oxygenation: a case report

BACKGROUND

Cardiac tamponade may present with very different signs and clinical consequences in patients who are supported with venoarterial extracorporeal membrane oxygenation. Failure to recognize cardiac tamponade in this setting can cause failure to wean from venoarterial extracorporeal membrane oxygenation, and even lead to death.

CASE PRESENTATION

We present a 44-year-old Caucasian female in whom cardiac tamponade manifested as venoarterial extracorporeal membrane oxygenation weaning failure. After discovering the contribution of cardiac tamponade, it was possible to wean the patient from venoarterial extracorporeal membrane oxygenation support. No clear signs of cardiac tamponade had existed beforehand.

CONCLUSIONS

The diagnosis of cardiac tamponade can be very challenging in venoarterial extracorporeal membrane oxygenation supported patients due to (patho)physiological particularities related to the parallel blood flow.

The ABCDE approach to difficult weaning from venoarterial extracorporeal membrane oxygenation

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been increasingly applied in patients with cardiogenic shock in recent years. Nevertheless, many patients cannot be successfully weaned from VA ECMO support and 1-year mortality remains high. A systematic approach could help to optimize clinical management in favor of weaning by identifying important factors in individual patients. Here, we provide an overview of pivotal factors that potentially prevent successful weaning of VA ECMO. We present this through a rigorous approach following the relatable acronym ABCDE, in order to facilitate widespread use in daily practice.

Obstructive Shock, from Diagnosis to Treatment

Shock is a life threatening pathological condition characterized by inadequate tissue oxygen supply. Four different subgroups of shock have been proposed according to the mechanism causing the shock. Of these, obstructive shock is characterized by reduction in cardiac output due to noncardiac diseases. The most recognized causes include pulmonary embolism, tension pneumothorax, pericardial tamponade and aortic dissection. Since obstructive shock typically cannot be stabilized unless cause for shock is resolved, diagnosis of the underlying disease is eminent. In this review, we therefore focus on diagnosis of obstructive shock and suggest a structured approach in three steps including clinical examination, ultrasound examination using the rapid ultrasound in shock (RUSH) protocol and radiological imaging if needed.

When is tamponade not an echocardiographic diagnosis… Or is it ever?

Although cardiac tamponade remains a clinical diagnosis, echocardiography is an essential tool to detect fluid in the pericardial space. Interpretation of echocardiographic findings and assessment of physiologic and hemodynamic consequences of a pericardial effusion require a thorough understanding of pathophysiologic processes. Certain echocardiographic signs point toward the presence of cardiac tamponade: a dilated inferior vena cava (IVC), collapse of the cardiac chambers, an inspiratory bulge of the interventricular septum into the left ventricle (LV) (the "septal bounce"), and characteristic respiratory variations of Doppler flow velocity recordings. However, in certain circumstances (e.g., mechanical ventilation, post-surgical patients, and pulmonary hypertension), these echocardiographic signs can be missing, despite the presence of clinical tamponade. Failure to recognize a potentially life-threatening clinical condition due to the absence of corresponding echocardiographic findings can delay both diagnosis and life-saving treatment. Thus, in the context of critical care, echocardiography should only be used to confirm the presence of pericardial fluid or localized hematoma, and the diagnosis of tamponade should rely on clinical criteria.

Cardiac tamponade in venoarterial extracorporeal membrane oxygenation

Cardiac tamponade is a challenging diagnosis in the unstable patient requiring extracorporeal membrane oxygenation. We present a case of cardiac tamponade secondary to hemorrhagic pericardial effusion that developed in the setting of cardiopulmonary resuscitation and venoarterial extracorporeal membrane oxygenation. Specifically, we aim to discuss the pertinent diagnostic challenges in confirming this diagnosis.

Cardiac Tamponade Complicating Extracorporeal Membrane Oxygenation: A Single-Centre Experience

BACKGROUND

Cardiac tamponade is a potential complication during extracorporeal membrane oxygenation (ECMO).

METHOD

This study assessed the incidence, clinical presentation, therapeutic approach, and outcome of cardiac tamponade at a single ECMO centre during a 10-year period.

RESULTS

Cardiac tamponade occurred in 11 adults (seven men; age 53 years [range, 48-60]) of 566 patients (1.9%), after 10 days (range, 3-16) of ECMO support: eight veno-venous (VV) and three veno-arterial (VA). Cardiac tamponade was suspected due to haemodynamic deterioration or collapse, and was confirmed by bedside echocardiography. In five of eight VV-ECMO (62%) patients, circulatory arrest ensued and immediate VA-ECMO conversion was performed. Definitive treatment of cardiac tamponade consisted of surgical pericardiotomy in 10 cases: sternotomy (n=8), left minithoracotomy (n=1) and subxiphoid approach (n=1); and pericardiocentesis in one patient. Cardiovascular perforation repair was performed in five patients: two right atrium, two superior vena cava and one pulmonary artery. In the remaining six patients, cardiac tamponade was associated with recent cardiac surgery (n=2), prolonged cardiopulmonary resuscitation (n=1), thoracic trauma (n=1), myopericarditis (n=1), and acute myocardial infarction (n=1). Nine (9) patients (82%) were weaned from ECMO (20 days [range, 11-25]) and eight patients (73%) survived intensive care unit (ICU) (29 days [range, 26-61]) and hospital (34 days [range, 29-81]).

CONCLUSION

Cardiac tamponade is a rare but life-threatening complication during both VV-ECMO and VA-ECMO. Echocardiography plays a major role in timely diagnosis and treatment. Immediate conversion to VA-ECMO when circulatory collapse ensued and emergency sternotomy for cardiovascular perforation repair gave favourable outcomes in a high proportion of patients.

ECMO and Right Ventricular Failure: Review of the Literature

Right ventricular (RV) failure is the inability of the RV to maintain sufficient cardiac output in the setting of adequate preload, due to either intrinsic injury to the RV or increased afterload. Medical treatment of RV failure should include optimizing preload, augmenting contractility with vasopressors and inotropes, and considering inhaled pulmonary vasodilators. However, when medical therapies are insufficient, mechanical circulatory support (MCS) is needed to maintain systemic and RV perfusion. The data on MCS for isolated RV failure are limited, but extracorporeal membrane oxygenation (ECMO) appears to be the most efficient and effective modality. For patients with isolated RV failure from acute hypoxemic respiratory failure, veno-venous (VV) ECMO is an appropriate initial configuration, even if the patient is in shock. With primary RV injury or RV failure with concomitant left ventricle (LV) failure, however, venoarterial (VA) ECMO is indicated. Both modalities provide indirect support to the RV by reducing preload, reducing RV wall tension, and delivering oxygenated blood to the coronary circulation. Peripheral cannulation is required in VV-ECMO and is most commonly used in VA-ECMO, allowing for rapid cannulation even in emergencies. Changes in pulsatility on an arterial catheter waveform can indicate changes in clinical status including changes in myocardial function, inadequate preload, worsening RV failure, and excessive VA-ECMO support leading to an elevated LV afterload. Myocardial function may be improved by titration of inotropes or vasodilators, utilization of an Impella or an intra-aortic balloon counterpulsation support devices, or by changes in VA-ECMO support.