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Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation

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Abstract

Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.

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Author information

Authors and Affiliations

  1. Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada

    Ghislaine Douflé, Laura Dragoi, Diana Morales Castro & Eddy Fan

  2. Department of Anesthesia and Pain Management, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada

    Ghislaine Douflé

  3. Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia

    Kei Sato & John F. Fraser

  4. Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia

    Kei Sato & John F. Fraser

  5. Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands

    Dirk W. Donker

  6. Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands

    Dirk W. Donker

  7. Service de Médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France

    Nadia Aissaoui

  8. Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium

    Hannah Schaubroeck

  9. Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK

    Susanna Price

  10. National Heart and Lung Institute, Imperial College London, London, UK

    Susanna Price

  11. Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France

    Alain Combes

  12. Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France

    Alain Combes

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  1. Ghislaine Douflé
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  6. Nadia Aissaoui
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  7. Eddy Fan
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  10. John F. Fraser
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  11. Alain Combes
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Contributions

GD, JF, AC planned the review. GD, LD, KS, DMC wrote the first draft. All authors were involved in critical revision of the final manuscript and approved it.

Corresponding author

Correspondence to Ghislaine Douflé.

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Conflicts of interest

EF disclosed receiving consulting fees from ALung Technologies, Baxter, Getinge, Inspira, Vasomune, Zoll Medical and honoraria from Getinge. AC disclosed receiving honoraria from Getinge, Baxter and Xenios. DWD disclosed receiving grants contract from Maquet and Sonion which were paid to the University of Twente, Netherlands as well as consulting fees from Hbox therapies. HS received honoraria from Astra Zeneca and received support from 3CT to attend 3CT workshops. DMC received a Canadian Institutes of Health Research (CIHR) Research Excellence, Diversity, and Independence (REDI) Early Career Transition Award. All other authors have disclosed that they do not have any conflict of interest.

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Supplementary Information

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Transthoracic parasternal long axis view of a patient referred immediately post-partum for consideration of venovenous ECMO for severe respiratory failure. The mitral valve is calcified and exhibits a typical diastolic doming consistent with rheumatic heart disease. The left atrium is severely dilated. The transmitral gradient calculated at 19 mmHg with a heart rate of 83 beats/ minute indicated very severe mitral stenosis. The hypoxemia improved with aggressive diuresis and the patient was later referred to cardiac surgery. LA: left atrium; LV: left ventricle; RV: right ventricle.  Supplementary file1 (MP4 4934 KB)

Transesophageal upper-esophageal view of the superior vena cava depicting a thrombus. Right PA: right pulmonary artery; SVC: superior vena cava.  Supplementary file2 (MP4 2904 KB)

Patient referred for consideration for venovenous ECMO for severe hypoxemic respiratory failure. Transthoracic view obtained from a window more posterior than a transthoracic apical 4-chamber view, depicting a large left pleural effusion. A left thoracocentesis was performed with a significant improvement in oxygenation. ECMO was not required in that case. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle Supplementary file3 (MP4 5198 KB)

Supplementary appendix Supplementary appendix Supplementary file4 (DOCX 55 KB)

Transthoracic subcostal bicaval view. This view is obtained from the subcostal window with the marker of the probe directed cephalad with a slight tilt of the probe towards the patient’s right. A cephalad rocking movement may also be required. Small rotational movements may be needed to open the superior vena cava. IVC: inferior vena cava; LA: left atrium; RA: right atrium; SVC: superior vena cava.  Supplementary file5 (MP4 8003 KB)

Transesophageal view of the inferior vena cava (IVC) at the gastro-esophageal junction. The 3-dimensional biplane function was activated allowing visualization of the IVC in long (left) and short axis (right). Note that on the long axis only one wire can be visualized, while both wires were within the IVC.  Supplementary file6 (MP4 3092 KB)

134_2024_7333_MOESM7_ESM.pdf

Main ultrasound windows for patients on VA ECMO from cannulation to decannulation.  a. Ultrasound image of a vessel with guidewire within it b. Truncated transesophageal midesophageal bicaval view with the venous wire in the superior vena cava. LA: left atrium; RA: right atrium; SVC: superior vena cavac. Transesophageal view of the descending aorta with the arterial wire seen in 2 orthogonal planes with the biplane function d. Truncated transesophageal midesophageal bicaval view with drainage cannula with its tip at the right atrium-superior vena cava junction. LA: left atrium; RA: right atrium; SVC: superior vena cava e. Transthoracic parasternal long axis view showing a non-opening aortic valve and spontaneous echocardiographic contrast in the ascending aorta. LA: left atrium; LV: left ventricle; RV: right ventriclef. Transcranial Doppler depicting the left MCA. ACA: anterior cerebral artery; CP: cerebral peduncles; MCA: middle cerebral arteryg. Transthoracic apical 4-chamber view of a patient on VA ECMO with an atrial septostomy. LA: left atrium; LV: left ventricle; RA: right atrium; right ventricleh. Transesophageal midesophageal long axis view of a patient on VA ECMO with an Impella® device. LA: left atrium; LV: left ventricle i. Transthoracic subcostal 4-chamber view showing a pericardial effusion. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle; P eff: pericardial effusion j. Transthoracic apical 4-chamber view with 3-dimensional assessment of the RV function. LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventriclek. Transesophageal deep transgastric view where the left ventricular outflow tract velocity time integral is measured during a weaning trial. LV: left ventricle. l. Transthoracic subcostal view of the inferior vena cava (IVC) post ECMO decannulation. A non-occlusive thrombus is seen within the IVC. Supplementary file7 (PDF 4486 KB)

Transesophageal view at the gastro-esophageal junction and midesophageal bicaval level showing the advancement of the drainage cannula over the femoral guidewire. LA: left atrium; RA: right atrium; SVC: superior vena cava.  Supplementary file8 (MP4 21101 KB)

Transesophageal view of the descending aorta showing the aortic guidewire on two orthogonal incidences with the biplane function. Supplementary file9 (MP4 1749 KB)

134_2024_7333_MOESM10_ESM.pdf

Main ultrasound windows for patients on VV ECMO (two-site cannulation) from cannulation to decannulation a. Ultrasound image of a vessel with guidewire within itb. Truncated transesophageal midesophageal bicaval view with two wires within the superior vena cava. LA: left atrium; RA: right atrium; SVC: superior vena cavac. Transesophageal midesophageal bicaval view with drainage cannula with its tip within the right atriumd. Ultrasound view of a densely consolidated lung of a patient on VV ECMO. The dense consolidation allows the visualization of the pulmonary artery with its segmental branches. PA: pulmonary arterye. Transthoracic right parasternal bicaval view depicting the drainage and return cannula in the inferior vena cava and superior vena cava, respectively. RA: right atriumf. Transthoracic parasternal right ventricular inflow-outflow view showing a drainage cannula with the tip abutting against the interatrial septum, which may in some cases cause drainage insufficiency. AV: aortic valve, LA: left atrium, PA: pulmonary artery, RA: right atrium, RV: right ventricleg. Transthoracic parasternal short axis view at the mid-papillary level showing a severely dilated right ventricle and significant paradoxical septal motion indicative of elevated pulmonary pressures. LV: left ventricle; RV: right ventricleh. Transthoracic subcostal 4-chamber view showing a pericardial effusion. LA: left atrium; LV: left ventricle; P eff: pericardial effusion; RA: right atrium; RV: right ventriclei. Transesophageal midesophageal bicaval view with a positive bubble study at the time of ECMO weaning with significant hypoxemia during trials off ECMO. LA: left atrium; RA: right atrium; SVC: superior vena cavaj. Transthoracic subcostal view of the inferior vena cava (IVC) post ECMO decannulation. A non-occlusive thrombus is seen within the IVC Supplementary file10 (PDF 278 KB)

Transesophageal midesophageal bicaval view showing both wires in both vena cavae. LA: left atrium; RA: right atrium. Supplementary file11 (MP4 3082 KB)

Panel A: transesophageal midesophageal bicaval view of a patient on VV ECMO with a femoro-femoral configuration. Panel B: modified midesophageal view showing the cannulae in short axis. The multistage drainage cannula is highlighted in blue, and the return cannula is in red. AV: aortic valve; LA: left atrium; RA: right atrium; RV: right ventricle; SVC: superior vena cava. Supplementary file12 (MP4 7071 KB)

Transesophageal midesophageal bicaval view of a patient being placed on VV ECMO. The multistage drainage cannula is seen within the right atrium, with its tip just below the superior vena cava-right atrial junction. LA: left atrium; RA: right atrium; SVC: superior vena cava. Supplementary file13 (MP4 2892 KB)

Transesophageal upper-esophageal view of the superior vena cava of a patient being placed on VV ECMO (femoro-jugular configuration). The return cannula is seen within the superior vena cava, with its tip a few centimeters above the superior vena cava-right atrial junction. RPA: right pulmonary artery; SVC: superior vena cava Supplementary file14 (MP4 3726 KB)

Transthoracic views of a patient already on VV ECMO support. Significant drainage insufficiency prompted a reconfiguration, as the initial drainage cannula was in the inferior vena cava and was abutting against the posterior wall of the IVC. An attempt at advancing the cannula was unsuccessful, as it kept abutting against the posterior wall of the IVC and could not be advanced further. Panel A: Right parasternal bicaval view (obtained with the probe parallel to the sternal border with the marker cephalad) showing the advancement of the new drainage cannula over the wire. Panel B: final position of the new drainage cannula with the tip at the superior vena cava-right atrium junction. Panel C: Parasternal right ventricular inflow-outflow. Thirteen days later, the cannula is seen to have inadvertently crossed the interatrial septum. Of note, there were no changes in the cannula position measured at the skin. AV: aortic valve; LA: left atrium; PA: pulmonary artery; RA: right atrium; RV: right ventricle; SVC: superior vena cava. Supplementary file15 (MP4 9729 KB)

Transesophageal midesophageal bicaval view of a patient during cannulation with a dual-lumen bicaval cannula. The cannula is threaded over the guidewire until the tip is in the inferior vena cava. IVC: inferior vena cava; LA: left atrium; RA: right atrium; SHV: sus hepatic vein Supplementary file16 (MP4 17458 KB)

Transesophageal midesophageal bicaval view of a patient on VV ECMO with a dual-lumen bicaval cannula in place. LA: left atrium; RA: right atrium Supplementary file17 (MP4 4559 KB)

Transesophageal midesophageal bicaval view of a patient on VV ECMO with a dual-lumen bicaval cannula (same patient as in electronic supplementary material 17). The reinfusion flow can be seen on color flow Doppler within the right atrium and directed towards the tricuspid valve. LA: left atrium; RA: right atrium Supplementary file18 (MP4 2897 KB)

Panel A: transthoracic subcostal view showing a dual-lumen bicaval cannula with the tip within the inferior vena cava and the reinfusion hole in the right atrium. Panel B: same view as in panel A with color flow Doppler added with the reinfused blood directed towards the tricuspid valve. RA: right atrium  Supplementary file19 (MP4 3212 KB)

134_2024_7333_MOESM20_ESM.pdf

Main ultrasound windows for patients on VV ECMO with a dual-lumen bicaval cannula from cannulation to decannulation.a. Ultrasound image of a vessel with guidewire within itb. Truncated transesophageal midesophageal bicaval view with a wire within the superior vena cava, crossing the right atrium towards the inferior vena cava. LA: left atrium; RA: right atrium; SVC: superior vena cavac. Transesophageal midesophageal bicaval view with the dual-lumen-bicaval cannula (dlBC) crossing the right atrium. LA: left atrium; RA: right atriumd. Transesophageal midesophageal bicaval view with the dlBC crossing the right atrium with color flow Doppler showing the reinfusion flow directed towards the tricuspid valve. LA: left atrium; RA: right atriume. Ultrasound view of a densely consolidated lung of a patient on VV ECMO. The dense consolidation allows the visualization of the pulmonary artery with its segmental branches. PA: pulmonary arteryf. Transthoracic subcostal view showing the cannula traversing the RA and the tip in the inferior vena cava. IVC: inferior vena cava; RA: right atriumg. Transesophageal view of the inferior vena cava at the gastro-esophageal level. IVC: inferior vena cava; SHV: sus hepatic vein h. Transesophageal view of the inferior vena cava at the gastro-esophageal level with color flow Doppler showing an intra-hepatic reinfusion flow. Changes in lung volumes and position can change the relative position of the cannula in relationship to the cardiac chambers and should be checked in case of hypoxemia or elevation of liver enzymesi. Transthoracic parasternal short axis view at the mid-papillary level showing a severely dilated right ventricle and significant paradoxical septal motion indicative of elevated pulmonary pressures. LV: left ventricle; RV: right ventriclej. Transthoracic subcostal 4-chamber view showing a pericardial effusion. LA: left atrium; LV: left ventricle; P eff: pericardial effusion; RA: right atrium; RV: right ventriclek. Transesophageal midesophageal bicaval view with a positive bubble study at the time of ECMO weaning with significant hypoxemia during trials off ECMO. LA: left atrium; RA: right atrium; SVC: superior vena caval. Transthoracic subcostal view of the inferior vena cava post ECMO decannulation. A non-occlusive thrombus is seen within the IVC. IVC: inferior vena cava Supplementary file20 (PDF 321 KB)

Transesophageal midesophageal bicaval view of a patient on ECMO with a dual-lumen RA-PA cannula. LA: left atrium; RA: right atrium; SVC: superior vena cava.  Supplementary file21 (MP4 2380 KB)

Transesophageal midesophageal right ventricular inflow-outflow view of a patient on ECMO with a dual-lumen RA-PA cannula. The tip of the cannula is seen within the main pulmonary artery approximately three centimeters beyond the pulmonary valve. AV: aortic valve; LA: left atrium; PA: pulmonary artery; PV: pulmonary valve; RA: right atrium; RV: right ventricle. Supplementary file22 (MP4 3153 KB)

Transesophageal view: midesophageal right ventricular inflow-outflow view of a patient on ECMO with a dual-lumen RA-PA cannula. The reinfusion flow is seen with color flow Doppler within the main pulmonary artery. AV: aortic valve; LA: left atrium; PA: pulmonary artery; PV: pulmonary valve; RA: right atrium; RV: right ventricle.  Supplementary file23 (MP4 2958 KB)

134_2024_7333_MOESM24_ESM.pdf

Main ultrasound windows for patients on veno-pulmonary (V-PA) ECMO from cannulation to decannulation.a. Ultrasound image of a vessel with guidewire within itb. Transesophageal midesophageal right ventricular inflow-outflow view with the wire seen in the right atrium and ventricle and the pulmonary artery. AV: aortic valve; LA: left atrium; PA: pulmonary artery, RA: right atrium, RV: right ventriclec. Transesophageal midesophageal right ventricular inflow-outflow view with the cannula seen in the right atrium and ventricle, and its tip in the main pulmonary artery d. Transesophageal midesophageal right ventricular inflow-outflow view with the cannula seen in the right atrium and ventricle, and its tip in the main pulmonary artery. Color flow Doppler is showing the reinfusion flow in the main pulmonary arterye. Ultrasound view of a densely consolidated lung of a patient on veno-pulmonary ECMO. The dense consolidation allows the visualization of the pulmonary artery with its segmental branches. PA: pulmonary arteryf. Transthoracic parasternal short axis view at the mid-papillary level showing a severely dilated right ventricle and significant paradoxical septal motion indicative of elevated pulmonary pressures upon weaning of the flows. LV: left ventricle; RV: right ventricleg. Transthoracic subcostal 4-chamber view showing a pericardial effusion. LA: left atrium; LV: left ventricle; P eff: pericardial effusion; RA: right atrium; RV: right ventricleh. Transesophageal midesophageal bicaval view with a positive bubble study at the time of ECMO weaning with significant hypoxemia during trials off ECMO. LA: left atrium; RA: right atrium; SVC: superior vena cavaj. Transesophageal upper-esophageal longitudinal view of the superior vena cava post ECMO decannulation. A non-occlusive thrombus is seen within the superior vena cava. SVC: superior vena cava Supplementary file24 (PDF 257 KB)

Transthoracic views of a patient on peripheral VA ECMO with an intra-aortic balloon pump (IABP). Panels A (parasternal long axis view) and B (apical 4-chamber view) were obtained on ECMO flows between 2.2 and 2.7 l/min and IABP with a frequency of 1:1. Despite depicting a pulsatility on the arterial line tracing (with a pulse pressure of approximately 40 mmHg), the aortic valve is not opening, and significant spontaneous echocardiographic contrast is seen in the left ventricle and in the aortic root. On panels C and D, the IABP frequency was set at 1:2 and dobutamine and nitroprusside were initiated. There is significantly less spontaneous echocardiographic contrast seen in the left ventricle and the aortic valve opens with every cardiac contraction. AV: aortic valve; IABP: intra-aortic balloon pump; LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle Supplementary file25 (MP4 5765 KB)

Transthoracic right ventricular inflow-outflow view of a patient on peripheral VA ECMO and left atrial venting via a septostomy. The left atrium venting cannula is seen crossing the interatrial septum and is seen across the left atrium. AV: aortic valve; LA: left atrium; RA: right atrium; RV: right ventricle.  Supplementary file26 (MP4 2942 KB)

Same patient as in electronic supplementary material 26: Transthoracic apical 4-chamber view of a patient on peripheral VA ECMO and left atrial venting via a septostomy. Note the presence of significant residual spontaneous echocardiographic contrast. In addition, although, it seemed that the drainage cannula was crossing the interatrial septum, it was artifactual. It was verified from other views that the drainage cannula was in the superior vena cava.LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle.  Supplementary file27 (MP4 3009 KB)

Transesophageal view of a patient on VA ECMO and Impella®. Midesophageal long axis view depicting the Impella® across the aortic valve. LA: left atrium; LV: left ventricle. Supplementary file28 (MP4 4981 KB)

Panel A: transesophageal midesophageal bicaval view at the time of venovenous ECMO initiation. The tip of the drainage cannula is positioned at the superior vena cava-right atrium (SVC-RA) junction. The return cannula is approximately three cm above the SVC-RA junction. Tidal volumes were 400 ml. Panel B: day 7 of VV ECMO support. Despite high extracorporeal blood flow (5.9 l/min), the patient is now severely hypoxemic (SpO2 78%). Significant recirculation is seen macroscopically and on the pre-membrane blood gases. An echocardiogram was performed to reassess the cannula position. The tip of the drainage cannula is now seen at the mid-atrial level and the return cannula is now only one cm away from the SVC-RA junction. The different cannula position is most likely due to a diaphragmatic shift resulting from significant derecruitment (tidal volumes 35 ml). Panel C: the return cannula was pulled back two cm with a significant improvement in oxygenation (SpO2 improved to 95%) Supplementary file29 (MP4 7947 KB)

Transthoracic subcostal right ventricular inflow-outflow view showing a right atrium-pulmonary artery cannula with the tip in the left pulmonary artery branch. LPA: left pulmonary artery; PV: pulmonary valve; RA: right atrium; RA-PA cannula: right atrium-pulmonary artery cannula; RPA: right pulmonary artery; RV: right ventricle; TV: tricuspid valve. Supplementary file30 (MP4 8952 KB)

Transesophageal midesophageal right ventricular inflow-outflow view of a patient on peripheral VA ECMO. An effusion is seen along the right ventricular wall. Signs of pericardial constraint and hemodynamic compromise are difficult to appreciate given the current ECMO flows. Comparison with previous echocardiograms and decreasing the ECMO flows may help differentiate between small right ventricular size due to unloading from the VA ECMO versus actual cardiac chamber compression due to tamponade. AV: aortic valve; LA: left atrium; RA: right atrium; RV: right ventricle.  Supplementary file31 (MP4 2412 KB)

Transesophageal views of a patient on VA ECMO with a large circumferential pericardial effusion causing tamponade. Panels A (midesophageal long axis view of the left ventricle) and B (transgastric short axis of the left ventricle) before the evacuation of the pericardial effusion. At the time of the echocardiogram in panels A and B, the patient was on similar doses of vasopressors compared to the previous days (Norepinephrine 0.04 mcg/kg/min), urine output was maintained, and lactate was 1. ECMO flows were unchanged at 5.25 l/min with similar rotations per minute. There was, however, a significant decrease in arterial pulsatility (BP 78/75) which prompted a repeat echocardiogram. Of note, there was no pulsus paradoxus observed on the arterial line tracing before the patient lost their pulsatility; however, the tidal volumes were minimal (20 ml). Note the significant left ventricular systolic dysfunction and the minimal opening of the aortic valve. Panels C (midesophageal long axis view) and D (transgastric view at the mid-papillary level) after evacuation of the pericardial effusion. There was a significant improvement in left ventricular contractility. AV: aortic valve; LA: left atrium; LV: left ventricle. Supplementary file32 (MP4 5412 KB)

Transcranial Doppler obtained from the left temporal window of a patient on peripheral VA ECMO. Panel A: the left middle cerebral artery (MCA) is visualized. Anatomic landmarks are labeled; Panel B: same view as in panel A without anatomical landmarks. Only the left MCA, proximal right MCA and the left posterior cerebral artery are well imaged on this view. On panel C, absence of pulsatility is observed in the left MCA (Panel C). ACA: anterior cerebral artery; Ant Com: anterior communicating artery; CP: cerebral peduncles; MCA: middle cerebral artery; PCA: posterior cerebral artery; Post com: posterior communicating artery. Supplementary file33 (MP4 2599 KB)

Transthoracic 3-dimensional right ventricular ejection fraction of a patient on VA ECMO. Supplementary file34 (MP4 2214 KB)

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Summary of main parameters to be assessed during VA ECMO weaning trial. Transthoracic views of a patient on VA ECMO ready to be liberated from VA ECMO. Measurements done at baseline and at 1 liter/min of VA ECMO flow. a. Apical 2-chamber view. Ejection fraction measured with the Simpson’s biplane is 37% b. Tissue Doppler at the lateral mitral annulus on an apical 4-chamber. Systolic tissue Doppler mitral annular velocity is 10 cm/s c. Left ventricular outflow tract velocity time integral of 16 cm d. Parasternal short axis view at the mid-papillary level without significant ventricular interdependence e. Right ventricular fractional area of change on an apical 4-chamber (42%) f. Tissue Doppler at the lateral tricuspid annulus on an apical 4-chamber. Systolic tissue Doppler tricuspid annular velocity is 12 cm/s, g. Right ventricular free wall longitudinal strain of –14% h. Right ventricular 3-dimensional ejection fraction: 30%. Supplementary file35 (JPG 51 KB)

Transesophageal midesophageal 4-chamber view of a patient on VA ECMO with a severely depressed right ventricular strain. RV free wall systolic longitudinal (RVFWSL) strain is –0.7%, while a normal value should be –20% (more negative values represent better contractile function). LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle Supplementary file36 (MP4 1891 KB)

Transesophageal midesophageal 4-chamber view of a patient on VA ECMO with a severely depressed left ventricular strain. Global longitudinal strain average is –2.1%, while a normal value should be beyond –20% (more negative values represent better contractile function). LA: left atrium; LV: left ventricle; RA: right atrium; RV: right ventricle Supplementary file37 (MP4 1684 KB)

Transthoracic subcostal view of the inferior vena cava in long axis post ECMO decannulation. A non-occlusive thrombus is seen within the inferior vena cava (IVC) Supplementary file38 (MP4 3425 KB)

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Douflé, G., Dragoi, L., Morales Castro, D. et al. Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation. Intensive Care Med (2024). https://doi.org/10.1007/s00134-024-07333-7

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