LV Distension and ECLS Lungs - UK HealthCare CECentral presentation...the different indications and...
Transcript of LV Distension and ECLS Lungs - UK HealthCare CECentral presentation...the different indications and...
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LV Distension and ECLS Lungs
Kevin W. Hatton, MD, FCCM
Interim Vice-Chair for Anesthesiology Research Division Chief, Anesthesiology Critical Care Medicine
Program Director, Anesthesiology Critical Care Medicine Fellowship Associate Clinical Professor of Anesthesiology and Surgery
University of Kentucky College of Medicine
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Faculty Disclosure
• Neither I nor my spouse have any conflicts to disclose.
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• Gap = The decision to use VA-ECLS must be carefully weighed against possible complications. There are several possible adverse events that can occur and the practitioner should be aware of the most common.
• Need = The desired change/result in practice is to be aware of the different indications and possible complications for VA ECLS.
Educational Need/Practice Gap
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Upon completion of this educational activity, you will be able to:
1. Indicate the mechanisms for LV distension. 2. Describe the impact of LV distension on the patient.
Objectives
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• At the end of this presentation, learners will be able to: • Explain the mechanism for LV distension in VA ECLS • Describe the common complications of LV distension in VA ECLS • Devise a treatment plan for LV distension in VA ECLS
Expected Outcome
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• 68 year old male • Admitted with SOB and fatigue • Diagnosed with acute myocarditis • Despite IABP and inotropic support,
developed worsening cardiogenic shock
• Placed on peripheral VA ECLS • Initial improvement but
oxygenation worsens 1-2 days later
Introduction
Image from: Soleiani. Perfusion. 2012;27:326.
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• ECLS Venous Drainage = RA drained via catheter placed in femoral vein
• Allows significant decompression of right atrium and right ventricle
• Left ventricle continues to fill with blood • Some blood passes around the RA drainage
catheter to the RV • Some blood passes through collateral flow
between bronchial and pulmonary arterial circulatory systems
VA ECMO
Image from: https://twitter.com/ELSOOrg/status/1008426052505522176
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Retrograde Aortic Blood Flow
https://twitter.com/ELSOOrg/status/1008426052505522176 https://openi.nlm.nih.gov/detailedresult.php?img=PMC3968595_CCR-10-65_F1&req=4
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• Retrograde flow results in marked increase in LV afterload
• In failing LV, increased afterload may have direct effect on LV function • Increased LV wall stress and myocardial O2 consumption • LV and LA blood stasis and intra-cardiac thrombosis
• In addition, incompetent mitral valve may improve LV distension but
may lead to pulmonary edema • Increased LV dilatation • Increased LA pressure • Pulmonary edema
LV Distension
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• High pulmonary venous return to LV due to inadequate drainage from RA into the ECMO circuit
• Incorrect ECMO settings • Inappropriately placed RA cannula • Intrinsically high collateral blood flow between bronchial and pulmonary
circulations
• Failure of aortic valve to open • Absence of functional MR allowing retrograde LV off-loading • Aortic valve incompetency
Risk Factors for LV Distension
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121 patients requiring VA ECMO at single academic medical center LV Distension (LVD) defined by: • Radiographic pulmonary edema • PADBP > 25 mmHg 36 patients developed LVD (29.8%) • 9 treated with early LV
decompression
Definition of LV Distension
Image from: Truby. ASAIO J. 2017;63:257.
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• Clinical diagnosis • Chest radiography • ECHO (TTE or TEE) • Swan-Ganz Catheter • Serial BNP measures
Diagnostic Options
Image from: http://clipart-library.com/clipart/399334.htm
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TEE Images of LV Distension
Images from: Soleiani. Perfusion. 2012;27:326.
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The most important treatment to prevent complications of LV distension is to rapidly decompress LV.
Treatment of LV Distension
Image from: http://clipart-library.com/clipart/2703.htm
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Conservative Treatment of LV Distension
• Conservative therapies • Exclude mechanical problems with ECMO
• TTE to evaluate cannula positions • Aggressive diuretic therapy to reduce systemic overload • Inotropic therapy to improve myocardial function
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• IABP counter-pulsation • Atrial septal defect
• Percutaneous atrial septostomy • Surgical septostomy
• LV venting procedures • Open surgical procedure • Minimally-invasive procedures • Percutaneous procedures
Mechanical Treatment of LV Distension
Image from: http://clipart-library.com/clipart/8izrdaL4T.htm
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Published Venting Studies
Image from: Meani. Eur J Heart Failure Suppl. 2017;19:84.
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ECLS and IABP
Image from: Cheng. J Invasive Cardiol. 2015;27:453.
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• Surgical LV Vent Procedure • Most commonly used in patients with central cannulation • Catheter placed through right superior pulmonary vein into LA or LV • Connected with Y-connector to drainage side of ECLS circuit
• Transfemoral LV cannula drainage
• Impella 2.5 (Abiomed, Danvers, MA) • TandemHeart (CardiacAssist, Pittsburgh, PA)
LV Venting Procedures
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Transfemoral Percutaneous LV Cannula
Images from: Hong. ASAIO J. 2016;62:117.
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Edema Improved by Transfemoral Cannula
Images from: Hong. ASAIO J. 2016;62:117.
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• Case series of 5 patients requiring peripheral VA ECLS
• Impella 2.5 placed within 6 hours of VA ECLS in contralateral femoral artery • PCWP > 18 mmHg • Absent aortic valve opening • Enlarged LV on TEE
• Impella titrated to PCWP < 12 mmHg
LV Distension Improved by Impella Device
Image from: Cheng. ASAIO J. 2013;59:533.
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1. Optimize definition of LV distension in ECLS patients
2. Define population of ECLS patients who will benefit from LV
decompression procedure
3. Define optimum LV decompression procedure
Future Directions
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• LV distension is common in patients requiring peripheral VA ECLS for cardiogenic shock
• LV distension occurs because retrograde aortic blood flow significantly increases LV afterload
• LV distension may cause: • Increased LV wall stress, chamber diameter and myocardial O2 consumption • LV and LA blood stasis and intra-cardiac thrombosis • LA enlargement, pulmonary venous congestion and pulmonary edema
Conclusions
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• LV distension is primarily diagnosed with TEE but can also be seen through elevations in CVP, PAWP, and PADBP
• The treatment of LV distension is LV decompression: • Conservative treatments • IABP counter-pulsations • Surgical LV decompression • Percutaneous LV decompression
Conclusions