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TEE guidance in veno-venous extra-corporeal membrane oxyegnation

Do you have a patient with refractory hypoxemia who has failed all other ARDS management (low tidal volume ventilation, proning, inhaled pulmonary vasodilators, paralytics?

​Is the extracorporeal membrane oxygenation (ECMO) on their way and need procedural guidance?

The following guide will demonstrate how TEE is used to place VV ECMO cannulae. At the end of this guide is a video tutorial.

VV ECMO insertion

Bedside TEE can be useful for procedural guidance for when patients require V-V ECMO insertion for refractory ARDS.

Equipment required:
  • Re-site pre-existing central venous lines from right internal to other access sites
  • TEE probe with machine (and operator)
  • V-V ECMO cannulas, ECMO circuit
  • ECMO Team (surgeon, perfusionist)

TEE and lung ultrasound

TEE can also be useful to screen for concomitant cardiac disease, which may change the type of ECMO required (e.g. cardiomyopathy requiring V-A ECMO)
​
TEE can also be used to screen for concomitant lung disease (e.g. pleural effusions), to see if there is any further optimization that can be performed prior to V-V ECMO insertion.

VV ECMO procedural guidance: key principles

When inserting V-V ECMO, the most important views that you will be acquiring are the:

  • ME Bicaval View (~ 90 degrees)
  • Transgastric IVC view (~70-90 degrees)
    • Both assist the ECMO team with positioning of guidewire and cannula placement

assisting in wire and cannula placement

Using the ME Bicaval:

  • We follow the ECMO team’s guidewire down to the RA
  • We must follow the wire into the IVC, not to the RV (PRIOR TO dilation and cannulation)
    • ​This is for the dual-lumen bicaval V-V ECMO Avalon cannala (where ECMO infow and outflow are provided by the same cannula)

Using the TG IVC View:

  • We acquire this view by going from ME Bicaval (90 degrees), and then advancing the probe into the stomach (TG IVC view)
  • We focus on seeing the liver, IVC and watching the guidewire
  • We must follow the wire into the IVC (PRIOR TO dilation and cannulation)
    • Otherwise – for an Avalon catheter, it would migrate potentially into the RV, rather than stay in the IVC (and cause complications)​

Finally, head back to the ME Bicaval View:

  • If using a dual-lumen bicaval V-V ECMO Avalon cannala
    • We want to turn on our colour box to see where the V-V ECMO outflow cannula is directed to (basket)
    • Ideally, we want to aim the basket towards the RV (downwards toward the tricuspid valve)
      • ​This is to prevent recirculation of blood within just the RA

VV ECMO insertion tutorial

In this tutorial, we will breakdown procedural guidance of V-V ECMO cannula insertion

References

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  • Hemamalini P, Dutta P, Attawar S. Transesophageal Echocardiography Compared to Fluoroscopy for Avalon Bicaval Dual-Lumen Cannula Positioning for Venovenous ECMO. Ann Card Anaesth. 2020;23:283–287.
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  • Javidfar J, Wang D, Zwischenberger JB, Costa J, Mongero L, Sonett J, Bacchetta M. Insertion of Bicaval Dual Lumen Extracorporeal Membrane Oxygenation Catheter with Image Guidance. ASAIO Journal. 2011;57:203–205.
  • Zochios V, Roscoe A. Echocardiography as an Adjunct in Venovenous Extracorporeal Membrane Oxygenation. Journal of Cardiothoracic and Vascular Anesthesia. 2018;32:379–380.​
  • Bartlett RH, Gattinoni L. Current status of extracorporeal life support (ECMO) for cardiopulmonary failure. Minerva Anestesiol. 2010 Jul;76(7):534-40. 
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