Your activity: 4 p.v.

The role of TEE in the management of extracorporeal membrane oxygenation

The role of TEE in the management of extracorporeal membrane oxygenation
Authors:
Alina Nicoara, MD, FASE
Michael G Fitzsimons, MD
Yasmin Maisonave, MD
Section Editor:
Jonathan B Mark, MD
Deputy Editor:
Nancy A Nussmeier, MD, FAHA
Literature review current through: Nov 2022. | This topic last updated: Nov 10, 2021.

INTRODUCTION — Extracorporeal membrane oxygenation (ECMO) may be used as an escalation strategy to manage cardiorespiratory failure refractory to optimal medical therapy in settings such as failure to wean from cardiopulmonary bypass (CPB) and management of acute respiratory distress syndrome (ARDS). This topic addresses the role of transesophageal echocardiography (TEE) to guide insertion and positioning of ECMO cannulae, initial assessment of ECMO function including patient responses, and eventual weaning of ECMO support.

Uses of TEE during initiation and management of short-term mechanical circulatory support (MCS) devices such as percutaneous devices (eg, Impella, TandemHeart), extracorporeal pumps (eg, Centrimag), and the intra-aortic balloon pump (IABP) are addressed separately. (See "Short-term mechanical circulatory support: Initiation and management considerations".)

Indications for initiating ECMO and management of patients receiving such support, including use of ECMO to treat ARDS due to coronavirus disease 2019 (COVID-19), are addressed in other topics. (See "Extracorporeal membrane oxygenation (ECMO) in adults" and "COVID-19: Extracorporeal membrane oxygenation (ECMO)".)

GENERAL CONSIDERATIONS — ECMO may be used to manage decompensated acute severe heart or lung failure in which conventional therapies have been exhausted [1,2]. ECMO is typically easier to establish than mechanical circulatory support (MCS) with a ventricular assist device (VAD) and allows higher flow rates (up to 10 L/minute). Similar to cardiopulmonary bypass (CPB), ECMO can also support oxygenation, ventilation, circulation, heating, and cooling. However, unlike CPB, fluids cannot be administered directly via the ECMO circuit. (See "Short-term mechanical circulatory assist devices", section on 'Extracorporeal membrane oxygenation' and "Extracorporeal membrane oxygenation (ECMO) in adults".)

Components of an ECMO circuit include the gas exchange/heat exchange unit (oxygenator/heater), driving force (pump), and tubing. The two main configurations of ECMO are venoarterial (VA) ECMO for cardiorespiratory support, and venovenous (VV) ECMO for respiratory support.

Venoarterial ECMO — VA ECMO provides oxygenation, removes carbon dioxide, and supports both the right and left ventricles [2]. Thus, VA ECMO may be utilized to treat left or right heart failure, and also supports oxygenation and carbon dioxide removal if respiratory failure is present.

For VA ECMO, blood is drained from the venous system to an oxygenator-ventilator (ie, artificial lung), with return of the oxygenated blood to the systemic circulation [2-4]. Blood drainage to the oxygenator-ventilator is performed via large-bore cannulas placed in the right atrium (RA), either by direct surgical cannulation or through a cannula placed in a large vein (most commonly femoral vein and inferior vena cavae [IVC]) (figure 1). After oxygenation and carbon dioxide removal in the ECMO oxygenator-ventilator, blood is returned through a cannula placed centrally in the ascending aorta or peripherally into a large artery. Thus, blood flow through the lungs is minimized.

Venovenous ECMO — VV ECMO effectively provides oxygenation and removes carbon dioxide from the blood, thereby replacing the function of the lungs; left and right ventricular function is necessary since VV ECMO does not supply cardiac support [2]. Therefore, it can be used in patients with adequate cardiac function but severe respiratory failure (eg, non-cardiogenic pulmonary edema associated with protamine reactions, transfusion-related acute lung injury [TRALI], ARDS) [5]. Notably, resolution of severe hypoxemia and hypercapnia may substantially decrease pulmonary vascular resistance, reduce RV afterload, and thereby improve RV function [3].

For VV ECMO, blood is drained from the venous system to an oxygenator-ventilator, with return of the oxygenated blood to the right side of the heart where it subsequently passes through the lungs, left side of the heart, and eventually into the systemic circulation (figure 2). Blood drainage is via cannulae placed through the femoral vein and positioned in the IVC and/or cannulae placed in the superior vena cava (SVC) through the right internal jugular (IJ) vein [2]. After oxygenation and carbon dioxide removal in the ECMO oxygenator-ventilator, blood is returned to the RA via a cannula placed in the femoral vein or the right IJ vein. Thus, blood flow through the lungs is maintained.

An alternative is insertion of a dual-lumen single cannula, which allows drainage of blood from both the SVC and IVC, with return of oxygenated blood into the RA [2,6].

Other ECMO configurations

Venovenoarterial (VVA) ECMO is a variant of VA ECMO involving insertion of a second cannula for improved venous drainage, resulting in a triple cannulation configuration. Conversion to VVA ECMO may be needed in situations where inadequate venous blood drainage results in excessive shunting of deoxygenated blood through the lungs.  

Venoarteriovenous (VAV) ECMO is a combination of both VV and VA ECMO that provides both respiratory and cardiac support. Blood is drained from the RA, undergoes oxygenation and carbon dioxide removal, then is returned into both the RA and the ascending aorta.

USES OF ECHOCARDIOGRAPHY FOR EXTRACORPOREAL MEMBRANE OXYGENATION — Echocardiography is a valuable diagnostic and monitoring tool often used before and during ECMO support [2,4,7-11]. Consensus statements for perioperative management of ECMO include guidance regarding the role of transesophageal echocardiography (TEE) in performing patient assessments before initiating ECMO, facilitating insertion and final positioning of ECMO cannulae, monitoring and troubleshooting during ECMO support, and managing the weaning process [2,11].

Assessment before initiation — Guidelines that describe the indications and practice of ECMO are published by the Extracorporeal Life Support Organization (ELSO) [12,13].

Assessment for underlying pathology and contraindications – Echocardiography is often employed before initiation of ECMO to determine indications and contraindications, and to deploy the type of ECMO appropriate for the underlying condition [7-9]. Either transthoracic echocardiography (TTE) or TEE can be used to (see 'General considerations' above and "Extracorporeal membrane oxygenation (ECMO) in adults"):

Identify reversible pathology as the cause of hemodynamic collapse such as cardiac tamponade, obstructive cardiomyopathy, or systolic anterior motion of the mitral valve associated with mitral regurgitation.

Identify contraindications to deployment of venoarterial (VA) ECMO such as aortic dissection, or moderate or severe aortic insufficiency.

Identify contraindications to deployment of venovenous (VV) ECMO, such as severe RV or LV dysfunction, acute cor pulmonale, or proximal pulmonary artery emboli.

Focused examination before cannulae insertion – A focused examination should be performed to survey the cannulation sites:

The right atrium (RA) is evaluated for structures which may interfere with adequate positioning or function of the cannulae. Examples include interatrial septum aneurysm, interatrial septal defects (eg, atrial septal defects, large patent foramen ovale [PFO]), prominent Chiari network, presence of thrombi, and pacemaker or defibrillator leads.

For VA ECMO, the sites of arterial cannulation (ascending aorta, descending aorta) are evaluated for severe or mobile atherosclerosis.

For VV ECMO, tricuspid valve (TV) pathology (eg, tricuspid stenosis, previous TV replacement) is ruled out.

Cannula insertion and initiation — Cannulation for peripheral ECMO may be performed under fluoroscopic or echocardiographic guidance or a combination of both [2]. However, in emergency situations, ECMO may be initiated without either imaging modality.

Cannulation for ECMO may be either peripheral or central, as described below (image 1) [2,4,5,7,8,10,14]. TEE can be used to provide feedback regarding initial positioning of the guidewires and cannulae, and can detect misplacement with creation of a vascular injury. TEE is also used to assess final positioning of the cannulae and the degree of initial ventricular and/or atrial unloading [2,7-9].

Central cannulation — Central cannulation for ECMO is often used for postcardiotomy shock since the heart and vessels are already surgically exposed, and the existing cannulae for cardiopulmonary bypass (CPB) allow efficient transition to the ECMO circuit in most cases [2,15]. Furthermore, central cannulation for VA or VV ECMO is often easier, allows larger cannulae, and eliminates risk of femoral venous or arterial complications (eg, peripheral lower extremity ischemia associated with a large cannula in the femoral artery). The major disadvantage is that central cannulae may be less secure and dislodgement may cause life-threatening hemorrhage.

Central venous drainage cannulae may be placed in the RA or in both the superior vena cava (SVC) and inferior vena cava (IVC). Central return of blood to the patient may be accomplished via a cannula or graft placed in the aorta for VA ECMO, or in the pulmonary artery for VV ECMO.

Intraoperative TEE guidance is useful during central cannulation:

For confirming ideal positioning of a right atrial venous drainage cannula in the mid to upper RA, but not touching the RA walls, interatrial septum, or TV. Thus, unobstructed flow can be provided for either VA or VV ECMO, (image 2). Unintentional misplacement across a PFO into the left atrium (LA) may also be identified and corrected [16]. However, in most cases, the final position of the arterial return cannula cannot be visualized with TEE if location is in the more distal portion of the ascending aorta.

For VV ECMO, assessment of whether recirculation of blood through the extracorporeal circuit is occurring. Undesirable recirculation occurs when blood return to the patient is drained immediately back to the ECMO circuit through the drainage cannula, thereby not effectively delivering oxygenated blood to the systemic circulation. TEE may demonstrate cannula malposition. Correction of recirculation is accomplished by repositioning the cannulae with TEE guidance or fluoroscopy, or by transition from VV ECMO to VA ECMO.

Peripheral cannulation — Advantages of peripheral cannulation include absence of interference with closure of a sternotomy, more secure cannulae that are less easily dislodged compared with central cannulae, and easier decannulation (image 1).

TEE can be used to confirm the position of the guidewires, and also to confirm final positioning of the drainage and return cannulae [2].

Insertion and final positioning of peripheral drainage cannula:

Using a midesophageal (ME) bicaval TEE view, the guidewire is visualized advancing through the IVC or SVC into the RA. The echocardiographer should confirm that wire(s) do not pass into the RV through the TV or across a PFO into the LA. After initial positioning of the wire(s) has been accomplished, the repeated dilation of the skin and subcutaneous tissues that is typically necessary may dislodge the wire(s). Thus, wire positioning should be reconfirmed.

Cannula insertion over the wire can be visualized using TEE by starting from a ME bicaval view and focusing on the IVC-RA junction, then advancing the probe to visualize the IVC below the diaphragm. Close communication with the clinician placing the cannulae is critical since wire displacement or kinking during cannula insertion could result in perforation of vascular structures or inadequate venous drainage and oxygenation.

The final position of the drainage cannula should be mid-RA for VA ECMO and in the proximal IVC below the cavo-atrial junction for VV ECMO.

Insertion and final positioning of the return cannula:

For VV ECMO, peripheral venous return of oxygenated and decarboxylated blood is also accomplished via a femoral vein and IVC, or via right internal jugular (IJ) vein and SVC into the RA. Final positioning of the return cannula should be in a mid-RA location, away from the TV and interatrial septum. The drainage and return cannulae should not be in proximity to one another, optimally greater than 8 cm apart, since closer proximity may lead to recirculation and ineffective ECMO support (image 1).

For VA ECMO, peripheral arterial return of blood may be accomplished via a cannula inserted into a femoral artery and threaded up into the lower descending aorta, or via a graft anastomosed end-to-side to the axillary artery. A second guidewire can be visualized and confirmed to be in the descending aorta. However, the final position of the return cannula cannot be visualized using TEE, as it will be in the lower descending aorta.

Insertion and final positioning of the Avalon Elite dual-lumen bicaval single cannula for VV ECMO – TEE is necessary to visualize correct placement of the different components of this cannula [7-9,14]. The cannula is placed via the right IJ vein. The drainage port at the tip of the cannula should be below the cavoatrial junction in the proximal IVC and not in a hepatic vein. This can be visualized by starting from a ME bicaval view focusing on the IVC-RA junction, then advancing the probe to visualize the IVC below the diaphragm. The return port of the cannula should be mid-RA with orientation toward the TV to facilitate blood flow toward the TV and the RV.

Monitoring during ECMO support — Initial settings typically target a flow rate of 60 to 80 mL/kg/minute, although eventually flows up to 10 L/minute can be delivered [11,15]. Heparin is administered to keep the partial thromboplastin time at approximately 1.5 to 2 times normal once the patient is stable and not bleeding [2,15,17].

For patients on VA ECMO support, ventricular function is typically further supported with inotropes to facilitate LV ejection and prevent thrombus formation [11,18]. This is especially important during initiation of VA ECMO since injection of pressurized blood return into the ascending aorta or descending aorta may actually increase LV afterload and further decrease LV ejection. Other strategies for unloading the LV during VA ECMO support include placement of an intra-aortic balloon pump (IABP) or an Impella catheter (ECMELLA configuration) [19,20]. (See "Extracorporeal membrane oxygenation (ECMO) in adults", section on 'Initiation' and "Extracorporeal membrane oxygenation (ECMO) in adults", section on 'Maintenance'.)

The role of echocardiography is somewhat limited during the period of ECMO support, and findings should be integrated with hemodynamic, clinical, and ventilatory parameters. Nonetheless, TEE may be helpful to assess the initial degree of ventricular and/or atrial unloading, then to monitor biventricular function and the patient's further response to ECMO support [11]. For example, if LV ejection is minimal, it is important to detect spontaneous echo contrast in the LV or aortic root, which may place the patient at increased risk of thrombus formation. In addition, identification of LV distension is important as it may further LV ischemia and dysfunction, and requires strategies for LV decompression such as placement of an Impella device [11,15,20].

Presence and causes for low ECMO flow (eg, with spontaneous echo contrast in the LV and the aortic root), hypoxemia, or other complications can be identified [11,20,21]:

Hypovolemia. Echocardiographic findings include collapsed heart chambers, or IVC wall collapsing around the drainage cannula.

Cannula displacement (especially drainage cannula). Also, hypoxemia may be seen if a cannula is displaced so that the tips of the drainage and return cannulae are in close proximity, with resultant recirculation.

Partial occlusion of the drainage cannula by adjacent structures or thrombus. The LV and LA should be screened for the presence of stasis or thrombus. Newly inserted prosthetic valves in the mitral or aortic position are also at risk of forming thrombus, which may impede leaflet function [22].

Presence of cardiac tamponade. Evaluation for pericardial effusion and pericardial clot is performed using multiple midesophageal and transgastric views since these fluid collections may not be circumferential but rather loculated.

Presence of acute aortic or mitral regurgitation with LV distention.

Left ventricular outflow tract obstruction.

Presence of clot formation in the aortic root. Clot in this location may impede adequacy of blood flow to the coronary circulation and oxygen delivery and impede myocardial recovery. While this can occur in any patient, it is particularly important in patients with prosthetic aortic valves (bioprosthetic or mechanical).

Risk for clot formation in the aortic root is increased in the absence of aortic valve opening. The LV chamber can be intermittently assessed using TEE to confirm regular aortic valve opening (ideally with every beat) and the arterial pressure tracing is monitored to verify pulsatility.

Weaning

Weaning from venoarterial ECMO support — The decision to wean from VA ECMO support is complex and should be based on clinical, hemodynamic, and echocardiographic data after ECMO support for at least 48 hours. While details of weaning strategies are institution-dependent, the following pre-weaning criteria are typical (algorithm 1) [11,15,23]:

Clinical evidence of cardiac recovery with adequate LV and RV function assessed with echocardiography (TTE or TEE), decreased and stable requirements for inotropic and vasopressor agents, mean systemic arterial pressure >60 mmHg with pulsatility on the arterial waveform, stable heart rate and rhythm, acceptable central venous pressure values <15 mmHg (or <20 mmHg if isolated RV failure is present).

Adequate pulmonary function suggested by arterial oxyhemoglobin saturation, lung-protective ventilator settings, and arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) >200 mmHg on 30 to 40 percent FiO2, and absent or only mild pulmonary edema on a chest radiograph.

Stable end-organ (renal, hepatic, neurologic) function.

Reversible causes of cardiorespiratory failure all treated.

A suggested approach to weaning is shown in the algorithm (algorithm 1). Echocardiography (TEE or TTE) provides support before and during weaning [11,15,24] :

LV and RV function are assessed before and at each step during the weaning process. Measured echocardiographic parameters may include LV and RV dimensions, qualitative and quantitative descriptors of LV and RV function, such as LV ejection fraction, and mitral annulus lateral tissue Doppler peak systolic velocity (S’) as a contractility measure of global function of the LV, as well as measures of global function of the RV such as tricuspid annular plane systolic excursion reflecting longitudinal displacement of the tricuspid annulus during systole and tricuspid annulus tissue Doppler S’ reflecting longitudinal velocity of the tricuspid annulus during systole. Details regarding obtaining these measurements are available in other topics. (See "Transesophageal echocardiography in the evaluation of the left ventricle" and "Echocardiographic evaluation of left ventricular diastolic function in adults" and "Echocardiographic assessment of the right heart".)

As weaning progresses and the patient remains hemodynamically stable (without requiring significant increases in inotropic or vasopressor support), expected echocardiographic findings include evidence of recruitment of LV and/or RV function by visual assessment as well as quantitatively demonstrated by a progressive increase in LV outflow tract velocity time integral (VTI) or RV outflow tract VTI with decreased ECMO support.

ECMO cessation and decannulation typically occurs if all of the following echocardiographic and other criteria are met (algorithm 1) [11,15,23]:

LV function – LV ejection function >20 percent; LV outflow tract VTI ≥10 cm, and MV lateral S’ ≥6 cm/second; pulse pressure >20 mmHg; central venous blood oxygen content (CVO2) >60 percent on moderate doses of epinephrine and/or milrinone.

RV function – Adequate RV function on TTE or TEE; central venous pressure <15 mmHg (or <20 mmHg if isolated RV failure is present).

Respiratory function – pH >7.30 with sweep speed (defined as the rate that oxygen is delivered via the ECMO circuit) at 1 to 2 L/minute; PaO2:FiO2 >200 with FiO2 <60 percent. For extubated patients: no major change in respiratory status and respiratory rate <25 breaths/minute. For intubated patients on mechanical ventilation: peak inspiratory pressure >25 mmHg with positive end-expiratory pressure <12 mmHg.

Absence of severe vasodilation or shock – Lactate level <2 mmol/L on moderate doses of norepinephrine and/or vasopressin.

Further increases in inotropic support may be appropriate if weaning criteria are not met when decannulation is necessary due to evidence of vascular complications. Transition from VA ECMO to VV ECMO can be considered if biventricular function has recovered, but respiratory function remains inadequate.

Patients failing weaning criteria are reassessed for reversible causes of cardiorespiratory failure. Some may be candidates for mechanical circulatory support (MCS) (see "Short-term mechanical circulatory support: Initiation and management considerations") or heart transplantation (see "Anesthesia for heart transplantation"). Family consultation and palliative care are initiated to plan for withdrawal of ECMO support if neither MCS nor transplantation are planned.

Weaning from venovenous ECMO support — One or more trials of weaning the patient off ECMO should be performed prior to discontinuing ECMO permanently (algorithm 2). Once the decision has been made to discontinue ECMO, the cannulae are removed.

SUMMARY AND RECOMMENDATIONS

Configurations for extracorporeal membrane oxygenation (ECMO) include:

Venoarterial (VA) ECMO provides oxygenation, removes carbon dioxide, and supports both the right ventricle (RV) and left ventricle (LV). Blood drainage to the oxygenator-ventilator is performed via large-bore cannulae placed in the right atrium (RA), either by direct surgical cannulation or through a cannula placed in a large vein (most commonly femoral vein and inferior vena cavae [IVC]). Blood is returned through a cannula placed centrally in the ascending aorta or peripherally into a large artery. (See 'Venoarterial ECMO' above.)

Venovenous (VV) ECMO provides oxygenation and removes carbon dioxide from the blood, but does not supply cardiac support. Blood drainage to the oxygenator-ventilator is performed via cannulae placed through the femoral vein and positioned in the IVC, and/or superior vena cava (SVC) via the right internal jugular (IJ) vein. Blood is returned to the RA where it subsequently passes through the lungs, left side of the heart, and eventually into the systemic circulation (figure 2). An alternative is insertion of a dual-lumen single cannula, which allows drainage of blood from both the SVC and IVC and return of oxygenated blood into the RA. (See 'Venovenous ECMO' above.)

Less common variants are (see 'Other ECMO configurations' above):

-Venovenoarterial (VVA) ECMO involves insertion of a second cannula for improved venous drainage, resulting in a triple cannulation configuration.

-Venoarteriovenous (VAV) ECMO is a combination of both VV and VA ECMO that provides both respiratory and cardiac support by draining blood from the RA to the oxygenator-ventilator, then returning it back to both the RA and the ascending aorta.

Before initiation of ECMO, TEE is employed to assess indications and contraindications in order to deploy the appropriate type of ECMO and to perform a focused survey of the cannulation sites. (See 'Assessment before initiation' above.)

During insertion of central or peripheral cannulae, TEE is employed to facilitate the insertion process, examine final positioning of the cannulae, and assess the initial degree of ventricular and/or atrial unloading. (See 'Cannula insertion and initiation' above.)

During ECMO support, TEE is often used to monitor biventricular function and the patient's response to ECMO support, as well as to identify presence and causes for low ECMO flow, hypoxemia, or other complications. (See 'Monitoring during ECMO support' above.)

During each stage of weaning from VA ECMO or VV ECMO support, TEE may be used to assess LV and RV function (algorithm 1 and algorithm 2). (See 'Weaning from venoarterial ECMO support' above and 'Weaning from venovenous ECMO support' above.)

  1. Kwak J, Majewski MB, Jellish WS. Extracorporeal Membrane Oxygenation: The New Jack-of-All-Trades? J Cardiothorac Vasc Anesth 2020; 34:192.
  2. Mazzeffi MA, Rao VK, Dodd-O J, et al. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesth Analg 2021; 133:1459.
  3. Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for Adults: JACC Scientific Expert Panel. J Am Coll Cardiol 2019; 73:698.
  4. Hoyler MM, Flynn B, Iannacone EM, et al. Clinical Management of Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2020; 34:2776.
  5. Fierro MA, Daneshmand MA, Bartz RR. Perioperative Management of the Adult Patient on Venovenous Extracorporeal Membrane Oxygenation Requiring Noncardiac Surgery. Anesthesiology 2018; 128:181.
  6. Betancor J, Xu B, Rehman KA, et al. Transesophageal Echocardiographic Guidance of Venovenous Extracorporeal Membrane Oxygenation Cannula (Avalon Cannula) Repositioning. CASE (Phila) 2017; 1:150.
  7. Douflé G, Roscoe A, Billia F, Fan E. Echocardiography for adult patients supported with extracorporeal membrane oxygenation. Crit Care 2015; 19:326.
  8. Platts DG, Sedgwick JF, Burstow DJ, et al. The role of echocardiography in the management of patients supported by extracorporeal membrane oxygenation. J Am Soc Echocardiogr 2012; 25:131.
  9. Victor K, Barrett NA, Gillon S, et al. CRITICAL CARE ECHO ROUNDS: Extracorporeal membrane oxygenation. Echo Res Pract 2015; 2:D1.
  10. Zochios V, Roscoe A. Echocardiography as an Adjunct in Venovenous Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2018; 32:379.
  11. Mazzeffi MA, Rao VK, Dodd-O J, et al. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part II, Intraoperative Management and Troubleshooting. Anesth Analg 2021; 133:1478.
  12. https://www.elso.org/Portals/0/ELSO%20Guidelines%20General%20All%20ECLS%20Version%201_4.pdf (Accessed on July 23, 2018).
  13. Tsai HC, Chang CH, Tsai FC, et al. Acute Respiratory Distress Syndrome With and Without Extracorporeal Membrane Oxygenation: A Score Matched Study. Ann Thorac Surg 2015; 100:458.
  14. Griffee MJ, Tonna JE, McKellar SH, Zimmerman JM. Echocardiographic Guidance and Troubleshooting for Venovenous Extracorporeal Membrane Oxygenation Using the Dual-Lumen Bicaval Cannula. J Cardiothorac Vasc Anesth 2018; 32:370.
  15. Patel B, Diaz-Gomez JL, Ghanta RK, et al. Management of Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock. Anesthesiology 2021; 135:497.
  16. Navas-Blanco JR, Williams DV. Images in Anesthesiology: Inadvertent Extracorporeal Membrane Oxygenation Cannulation across a Patent Foramen Ovale. Anesthesiology 2019; 130:309.
  17. Sidebotham D, McGeorge A, McGuinness S, et al. Extracorporeal membrane oxygenation for treating severe cardiac and respiratory failure in adults: part 2-technical considerations. J Cardiothorac Vasc Anesth 2010; 24:164.
  18. Fierro MA, Dunne B, Ranney DN, et al. Perioperative Anesthetic and Transfusion Management of Veno-Venous Extracorporeal Membrane Oxygenation Patients Undergoing Noncardiac Surgery: A Case Series of 21 Procedures. J Cardiothorac Vasc Anesth 2019; 33:1855.
  19. Tschöpe C, Van Linthout S, Klein O, et al. Mechanical Unloading by Fulminant Myocarditis: LV-IMPELLA, ECMELLA, BI-PELLA, and PROPELLA Concepts. J Cardiovasc Transl Res 2019; 12:116.
  20. Desai SR, Hwang NC. Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:208.
  21. Tahir Janjua MS, Shukla S, Tantawy H. Pulsus Bisferiens on Extracorporeal Membrane Oxygenation. Anesthesiology 2021; 134:628.
  22. Chiang YP, Nicoara A, Milano CA. Temporary left ventricular assist device may be safer than veno-arterial extracorporeal membrane oxygenation for treating shock in the presence of a mitral prosthesis. JTCVS Tech 2020; 3:206.
  23. Aissaoui N, El-Banayosy A, Combes A. How to wean a patient from veno-arterial extracorporeal membrane oxygenation. Intensive Care Med 2015; 41:902.
  24. Nanjayya VB, Murphy D. Extracorporeal Life Support Organization. Ultrasound Guidance for Extra-corporeal Membrane Oxygenation Veno-arterial ECMO specific guidelines. https://www.elsoorg/Portals/0/Files/elso_Ultrasoundguidance_vaecmo_guidelines_May2015.pdf. (Accessed on January 27, 2021).
Topic 131002 Version 4.0

References