lv distension and ecls lungs
play

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

0 downloads 4 Views 1,57 MB Size Report
  1. 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

  2. Faculty Disclosure • Neither I nor my spouse have any conflicts to disclose.

  3. Educational Need/Practice Gap • 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.

  4. Objectives 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.

  5. Expected Outcome • 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

  6. Introduction • 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 Image from: Soleiani. Perfusion. 2012;27:326.

  7. VA ECMO • 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 Image from: https://twitter.com/ELSOOrg/status/1008426052505522176

  8. 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

  9. LV Distension • 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

  10. Risk Factors for LV Distension • 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

  11. Definition of LV Distension 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 Image from: Truby. ASAIO J. 2017;63:257.

  12. Diagnostic Options • Clinical diagnosis • Chest radiography • ECHO (TTE or TEE) • Swan-Ganz Catheter • Serial BNP measures Image from: http://clipart-library.com/clipart/399334.htm

  13. TEE Images of LV Distension Images from: Soleiani. Perfusion. 2012;27:326.

  14. Treatment of LV Distension The most important treatment to prevent complications of LV distension is to rapidly decompress LV. Image from: http://clipart-library.com/clipart/2703.htm

  15. 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

  16. Mechanical Treatment of LV Distension • IABP counter-pulsation • Atrial septal defect • Percutaneous atrial septostomy • Surgical septostomy • LV venting procedures • Open surgical procedure • Minimally-invasive procedures • Percutaneous procedures Image from: http://clipart-library.com/clipart/8izrdaL4T.htm

  17. Published Venting Studies Image from: Meani. Eur J Heart Failure Suppl. 2017;19:84.

  18. ECLS and IABP Image from: Cheng. J Invasive Cardiol. 2015;27:453.

  19. LV Venting Procedures • 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)

  20. Transfemoral Percutaneous LV Cannula Images from: Hong. ASAIO J. 2016;62:117.

  21. Edema Improved by Transfemoral Cannula Images from: Hong. ASAIO J. 2016;62:117.

  22. LV Distension Improved by Impella Device • 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 Image from: Cheng. ASAIO J. 2013;59:533.

  23. Future Directions 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

  24. Conclusions • 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

  25. Conclusions • 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

Recommend Documents


foundations of ecls skills training and hands on
FOUNDATIONS OF ECLS: SKILLS, TRAINING,

WELCOME TO FOUNDATIONS OF ECLS: SKILLS, TRAINING, AND HANDS ON MANAGEMENT

ecls program in the hub and spoke model
ECLS Program in the Hub and Spoke Model

ECLS Program in the Hub and Spoke Model Julia Akhtarekhavari, BSN, RN

we want an ecls program where to start regulations
We Want an ECLS Program Where to Start?

We Want an ECLS Program Where to Start? Regulations, Volumes, Staffing Needs

ecls program finances financial implications
ECLS Program Finances Financial

ECLS Program Finances Financial Implications Julie Parrish, MBA Business

1
1 Tracheobronchial Tree Anatomic

Chest and Lungs The chest and lungs allow for respiration Chapter 13 Purpose

modelling of mammalian lungs with hysteresis operators
Modelling of Mammalian Lungs with

Modelling of Mammalian Lungs with Hysteresis operators Denis Flynn

1
1 Reason As a SOF Medic your ability

SOCM Physical Exam of the Thorax and Lungs PFN: SOMPYL0Q Hours: 2.0

triggering the pns
Triggering the PNS When you inhale,

Triggering the PNS When you inhale, fill your lungs fully, hold for a second

1 2
1 2 Key Points: The respiratory

1 2 Key Points: The respiratory system delivers oxygen to the bloodstream

hspatlas com 75 cases
HSPATLAS.COM (75 cases) Lungs: 1. CMV

HSPATLAS.COM (75 cases) Lungs: 1. CMV pneumonia 2. hydatid disease 3. acute

deep learning framework
DEEP LEARNING FRAMEWORK FOR

DEEP LEARNING FRAMEWORK FOR DIAGNOSTICS AND PATIENT-SPECIFIC DESIGN OF

specialist collaborative models
Specialist Collaborative Models RGPs

Optimizing Outcomes For Frail High Risk Seniors Through Specialist-Specialist

pharm acovigilance
Pharm acovigilance Joint plenary of

Pharm acovigilance Joint plenary of PCWP and HCPWP: September 2019 Dr Peter

clinical trial in patients with transthyretin amyloid
Clinical Trial in Patients with

Safety, Tolerability and Transthyretin Stabilization by AG10: A Phase 2,

for isolated aortic valves replacement
for Isolated Aortic Valves Replacement

A Multistate Analysis of the Readmission Rates for Isolated Aortic Valves

atrioventricular block as the initial presentation of
Atrioventricular block as the initial

See discussions, stats, and author profiles for this publication at:

basic
BASIC ECHOCARDIOGRAPHY HOW TO DO?

BASIC ECHOCARDIOGRAPHY HOW TO DO? Before echocardiography Patients

iv to p o iv to p o or iv to or iv to
IV to P.O. IV to P.O. or IV to or IV

En Endo docardit carditis is De Deba bate: te: IV to P.O. IV to P.O.

perioperative management of warfarin interruption
Perioperative Management of Warfarin

Faculty Disclosures Perioperative Management of Warfarin Interruption There

adult congenital heart disease
Adult Congenital Heart Disease Pankaj

Adult Congenital Heart Disease Pankaj Madan, MD, MS, Medical Director South

fetal cardiac fin indings in in rats exposed to tri
Fetal Cardiac Fin indings in in Rats

Fetal Cardiac Fin indings in in Rats Exposed to Tri richloroethylene (T

with your participation
with Your Participation Kuwait IM

Challenging Cases in Cardiology with Your Participation Kuwait IM Course,