Fig 3 - uploaded by Oana M. Dumitrascu
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Transcranial Doppler waveforms obtained from patients with continuous flow devices. (A) Venoarterial-extracorporeal membrane oxygenation (VA-ECMO): Waveforms in patient supported by VA-ECMO demonstrate continuous flow without clear systolic peaks. (B) Left ventricular assist devices (LVADs): Low pulsatility indices in patient with continuous-flow LVAD with native flow. ECMO = extracorporeal membrane oxygenation; LMCA = left middle cerebral artery; LVAD = left ventricular assist device; RMCA = right middle cerebral artery; Peak = peak systolic velocity; Dias = diastolic velocity; Mean = mean flow velocity; P.I. = pulsatility index.
Source publication
Background and purpose:
Mechanical circulatory support (MCS) devices are commonly used in heart failure patients. These devices carry risk for presumably embolic and additionally hemorrhagic stroke. Alterations in blood flow play a key role in stroke pathophysiology, and we aimed to learn more about hemodynamic compromise. In this study, we used t...
Contexts in source publication
Context 1
... in patients supported by VA-ECMO demonstrated continuous flow without clear systolic peaks (Fig 3A). The average (±SD) middle cerebral artery (MCA) MFV was 56.07 (±21) cm/seconds and PI was .43 ...
Context 2
... evaluated flow patterns in individual types of LVAD devices. In general, PIs were low in patients with continuous-flow LVADs ( Fig 3B). HMII average (±SD) MCA MFV was 57.3 (±12.9) ...
Context 3
... in patients supported by VA-ECMO demonstrated continuous flow without clear systolic peaks (Fig 3A). The average (±SD) middle cerebral artery (MCA) MFV was 56.07 (±21) cm/seconds and PI was .43 ...
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Citations
... Mean pulmonary arterial (bottom left panel) and right atrial (bottom right panel) pressures showed similar IABP assistance reduced E a /E es by more than 25% when Pv = −10 and Pd = 260 mmHg whilst Impella pump increased left ventricular-arterial coupling although inversely related to pump rotational speed (top left panel). Coronary, cerebral and renal blood flow increased with both Impella and IABP support (top right and bottom left and right panel in Figure 7) [22,25]. percentage increase on IABP support. ...
... IABP assistance reduced Ea/Ees by more than 25% when Pv = −10 and Pd = 260 mmHg whilst Impella pump increased left ventricular-arterial coupling although inversely related to pump rotational speed (top left panel). Coronary, cerebral and renal blood flow increased with both Impella and IABP support (top right and bottom left and right panel in Figure 7) [22,25]. ...
Cardiogenic shock (CS) is part of a clinical syndrome consisting of acute left ventricular failure causing severe hypotension leading to inadequate organ and tissue perfusion. The most commonly used devices to support patients affected by CS are Intra-Aortic Balloon Pump (IABP), Impella 2.5 pump and Extracorporeal Membrane Oxygenation. The aim of this study is the comparison between Impella and IABP using CARDIOSIM© software simulator of the cardiovascular system. The results of the simulations included baseline conditions from a virtual patient in CS followed by IABP assistance in synchronised mode with different driving and vacuum pressures. Subsequently, the same baseline conditions were supported by the Impella 2.5 with different rotational speeds. The percentage variation with respect to baseline conditions was calculated for haemodynamic and energetic variables during IABP and Impella assistance. The Impella pump driven with a rotational speed of 50,000 rpm increased the total flow by 4.36% with a reduction in left ventricular end-diastolic volume (LVEDV) by ≅15% to ≅30%. A reduction in left ventricular end systolic volume (LVESV) by ≅10% to ≅18% (≅12% to ≅33%) was observed with IABP (Impella) assistance. The simulation outcome suggests that assistance with the Impella device leads to higher reduction in LVESV, LVEDV, left ventricular external work and left atrial pressure-volume loop area compared to IABP support.
... IABP assistance reduced Ea/Ees by more than 25% when Pv=-10 and Pd=260 mmHg whilst Impella pump increased left ventricular-arterial coupling although inversely related to pump rotational speed (top left panel). Coronary, cerebral and renal blood flow increased with both Impella and IABP support (top right and bottom left and right panel in Figure 6) [19], [23]. Left ventricular external work (LVEW) decreased by more than 20% compared to baseline conditions on IABP assistance with Pd= 260 mmHg and Pv=-10 (top left panel in Figure 7). ...
Cardiogenic shock (CS) is part of a clinical syndrome consisting of acute left ventricular failure causing severe hypotension leading to inadequate organ and tissue perfusion. The most com-monly used devices to support patients affected by CS are Intra-Aortic Balloon Pump (IABP), Impella 2.5 pump and Extracorporeal Membrane Oxygenation. The aim of this study is the com-parison between Impella and IABP using CARDIOSIM© software simulator of the cardiovascular system. The results of the simulations included baseline conditions from a virtual patient in CS followed by IABP assistance in synchronized mode with different driving and vacuum pressures. Subsequently, the same baseline conditions were supported by the Impella 2.5 with different ro-tational speeds. The percentage variation with respect to baseline conditions was calculated for hemodynamic and energetic variables during IABP and Impella assistance. Impella pump driven with a rotational speed of 50000 rpm increased the total flow by 4.36% with a reduction in left ventricular end diastolic volume (LVEDV) by ≅15% to ≅30%. A reduction in left ventricular end systolic volume (LVESV) by ≅10% to ≅18% (≅12% to ≅33%) was observed with IABP (Impella) as-sistance. Taking into account the limitations of a simulation setting, this study highlights that assistance with the Impella device leads to higher reduction in LVESV, LVEDV, left ventricular external work and left atrial pressure-volume loop area compared to IABP support.
... Because of the relative rarity of ECMO and the high operator proficiency required of TCD, data regarding cerebral hemodynamics and their clinical significance in this population remain limited. To date, five articles have recently described cerebral hemodynamics in ECMO patients, but with sample sizes ranging from 8-53 patients and limited clinical correlation with relevant hemodynamic parameters or clinical follow-up [13][14][15][16][17]. In this study, intracranial artery mean flow velocities (MFVs) and pulsatility indices (PIs) were captured in a large, clinically well-characterized cohort of VA-ECMO and VV-ECMO patients to describe cerebral hemodynamics, clinical correlates, and neurologic outcomes with TCD use in this population. ...
Background:
Extracorporeal membrane oxygenation has a high risk of acute brain injury and resultant mortality. Transcranial Doppler characterizes cerebral hemodynamics in real time, but limited data exist on its interpretation in ECMO. Here, we report TCD mean flow velocity and pulsatility index in a large ECMO population.
Methods:
This was a prospective cohort study at a tertiary care center. The patients were adults on venoarterial ECMO or venovenous ECMO undergoing TCD studies.
Results:
A total of 135 patients underwent a total of 237 TCD studies while on VA-ECMO (n = 95, 70.3%) or VV-ECMO (n = 40, 29.6%). MFVs were captured reliably (approximately 90%) and were similar to a published healthy cohort in all vessels except the internal carotid artery. Presence of a recordable PI was strongly associated with ECMO mode (57% in VA vs. 95% in VV, p < 0.001). Absence of TCD pulsatility was associated with intraparenchymal hemorrhage (14.7 vs. 1.6%, p = 0.03) in VA-ECMO patients.
Conclusions:
Transcranial Doppler analysis in a single-center cohort of VA-ECMO and VV-ECMO patients demonstrates similar MFVs and PIs. Absence of PIs was associated with a higher frequency of intraparenchymal hemorrhage and a composite bleeding event. However, cautious interpretation and external validation is necessary for these findings with a multicenter study with a larger sample size.
... In some patients with certain types of cardiac contractility, a systolic peak of cerebral blood flow existed, but the PI value was usually lower than normal. As the cardiac systolic function changed, the patient's cerebral hemodynamics and PI value were also seen to change (Figure 4). is finding is consistent with International Journal of Clinical Practice several previous studies [19,21,22]. Kavi et al. [19] pointed out that the existence of low PI can be explained by the pulse produced by a severely weakened but mildly preserved cardiac systolic function, and such a patient should not be considered for either cerebral vasodilation or cerebral circulation arrest protocols. ...
Objective:
Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) support may have cerebral hemodynamic changes whose impact on patient outcome are not fully elucidated. This study aims to evaluate the correlation between cerebral hemodynamic changes and prognostic outcome in patients during VA-ECMO.
Methods:
Transcranial Doppler (TCD) ultrasound examination was performed to attain the systolic velocity (Vs), diastolic velocity (Vd), mean velocity (Vm), and pulsatility index (PI) of patients undergoing VA-ECMO. Cardiac ultrasound was also performed to assess the correlation between the left ventricular outflow tract velocity time integral (LVOT VTI), left ventricular ejection fraction (LVEF), and middle cerebral artery (MCA) with the systolic peak. Moreover, we assessed the predictive value of LVOT VTI and LVEF in patients with the systolic peak. Patients were divided into survival and death groups according to the 28-day survival period. Clinical data were compared between the two groups to investigate the effects of cerebral hemodynamic changes on the prognosis of VA-ECMO patients.
Results:
We found that the patient's LVOT VTI and LVEF had high predictive values for the systolic peak of the right middle cerebral artery. The initial LVEF, Vs, Vd and PI, and lactate level as well as the MODS incidence rate difference were significantly different between the survival and death groups. In addition, the results showed that the initial Vs value was an independent risk factor for the prognosis of patients undergoing VA-ECMO.
Conclusions:
Cerebral hemodynamic changes may occur in patients supported by VA-ECMO. In addition, a poor cerebral arterial pulsatile blood flow was closely correlated with an unfavorable outcome in these patients.
... Understanding the changes in CBF is helpful to detect new vascular injury during ECMO support and to optimize cerebral perfusion. TCD and TCCD have been applied to stroke, TBI, hypoxic-ischemic encephalopathy, and neurological monitoring during ECMO support (36)(37)(38)(39). Point-of-care ultrasound (PoCUS) visualization management of ECMO patients has played an important role in identifying indications, catheterization, flow adjustment, volume management, cardiac function evaluation, etc. ...
Background
The main objective of this study was to investigate the role of a multimodal neurological monitoring (MNM)-guided protocol in the precision identification of neural impairment and long-term neurological outcomes in venoarterial extracorporeal membrane oxygenation (VA-ECMO) supported patients.
Methods
We performed a cohort study that examined adult patients who underwent VA-ECMO support in our center between February 2010 and April 2021. These patients were retrospectively assigned to the “with MNM group” and the “without MNM group” based on the presence or absence of MNM-guided precision management. The differences in ECMO-related characteristics, evaluation indicators (precision, sensitivity, and specificity) of the MNM-guided protocol, and the long-term outcomes of the surviving patients were measured and compared between the two groups.
Results
A total of 63 patients with VA-ECMO support were retrospectively assigned to the without MNM group ( n = 35) and the with MNM group ( n = 28). The incidence of neural impairment in the without MNM group was significantly higher than that in the with MNM group (82.1 vs. 54.3%, P = 0.020). The MNM group exhibited older median ages [52.5 (39.5, 65.3) vs. 31 (26.5, 48.0), P = 0.008], a higher success rate of ECMO weaning (92.8 vs. 71.4%, P = 0.047), and a lower median duration of building ECMO [40.0 (35.0, 52.0) vs. 58.0 (48.0, 76.0), P = 0.025] and median ECMO duration days [5.0 (4.0, 6.2) vs. 7.0 (5.0, 10.5), P = 0.018] than the group without MNM. The MNM-guided protocol exhibited a higher precision rate (82.1 vs. 60.0%), sensitivity (95.7 vs. 78.9%), and specificity (83.3 vs. 37.5%) in identifying neural impairment in VA-ECMO support patients. There were significant differences in the long-term outcomes of survivors at 1, 3 and 6 months after discharge between the two groups ( P < 0.05). However, the results showed no significant differences in ICU length of stay (LOS), hospital LOS, survival to discharge, or 28-day mortality between the two groups ( P > 0.05).
Conclusion
The MNM-guided protocol is conducive to guiding intensivists in the improvement of cerebral protection therapy for ECMO-supported patients to detect and treat potential neurologic impairment promptly, and then improving long-term neurological outcomes after discharge.
... TCD ultrasound offers significant diagnostic value for patients supported by ECMO, providing direct measurements of the pattern of cerebral blood flow, hemodynamic reserve, and microembolic signals (MESs). Waveforms in patients supported by VA ECMO were demonstrated as continuous flows without clear systolic peaks (58). Furthermore, TCD ultrasound can be used to calculate mean flow velocities and pulsatility indexes for patients on VA ECMO (59). ...
Extracorporeal membrane oxygenation (ECMO), a life-saving technique for patients with severe respiratory and cardiac diseases, is being increasingly utilized worldwide, particularly during the coronavirus disease 2019(COVID-19) pandemic, and there has been a sharp increase in the implementation of ECMO. However, due to the presence of various complications, the survival rate of patients undergoing ECMO remains low. Among the complications, the neurologic morbidity significantly associated with venoarterial and venovenous ECMO has received increasing attention. Generally, failure to recognize neurologic injury in time is reportedly associated with poor outcomes in patients on ECMO. Currently, multimodal monitoring is increasingly utilized in patients with devastating neurologic injuries and has been advocated as an important approach for early diagnosis. Here, we highlight the prevalence and outcomes, risk factors, current monitoring technologies, prevention, and treatment of neurologic complications in adult patients on ECMO. We believe that an improved understanding of neurologic complications presumably offers promising therapeutic solutions to prevent and treat neurologic morbidity.
