Extracorporeal Life Support (ECLS), formerly known as Extracorporeal Membrane Oxygenation (ECMO) for adult patients, is life-saving technology that is growing in its use and applicability. ECLS is a rescue therapy for critically ill patients with cardiac and/or respiratory systems that have failed maximal conventional medical therapy. ECLS systems are modified cardiopulmonary support devices that can provide support for days to months to allow organs to recover or decisions regarding longer-term mechanical support devices or transplantation to be made.
Venovenous (VV ECLS) provides adequate oxygenation and carbon dioxide removal in isolated refractory respiratory failure. Venoarterial (VA ECLS) support provides perfusion support in addition to oxygenation and carbon dioxide removal and is indicated for combined cardiac and respiratory failure or isolated cardiac failure. Improvements in portable technology and mobile support teams deployed from referral centers that initiate ECLS therapy in referral hospitals have spawned applications of this technology in a variety of hospitals. Patients are placed on ECLS by a transport team, then transferred to the ECLS referral center for longer-term care. Many physicians and echocardiographers may see this new technology in their own hospital. Ultrasound guidance for vascular access, transthoracic (TTE) and transesophageal (TEE) cardiac ultrasound are complimentary technologies that can guide safe cannulae placement, initiation of therapy and management.
The placement of a patient on ECLS requires a team approach. Critical to this team is a echocardiologist who understands that ultrasound and echocardiography can aid in patient selection, safe cannula insertion, monitor progress of therapy, detect complications, and help determine ultimate recovery and weaning strategies.
ECLS Patient Selection
A comprehensive TTE or TEE is important to help guide therapy in this group of critically ill adults who may benefit from ECLS therapy. Patients may demonstrate refractory hypoxemia, despite maximal ventilator support or hemodynamic instability despite maximal resuscitative efforts. Echocardiography can identify potentially reversible pathologic states, which may account for the patient’s hemodynamic or hypoxic condition. Common findings may include tamponade, acute severe mitral or aortic insufficiency, severe pulmonary hypertension, an intracardiac shunt, or severe right or left ventricular dysfunction. Alternative resuscitative maneuvers may be undertaken before ECLS is initiated to alleviate potentially reversible conditions. Echocardiography provides information regarding aortic dissections, which is a contraindication to VA ECLS. Significant conditions that may complicate VA or VV ECLS, identified by echocardiography, include a prominent patent foramen ovale (PFO), atrial septal defect (ASD), intra-arterial septal aneurysm, pacer and AICD leads, or tricuspid valvular disease. Echocardiograpy allows an assessment of cardiac function to guide VV versus VA ECLS.
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