title: Weaning of extracorporeal membrane oxygenation using continuous hemodynamic transesophageal echocardiography.
abstract: BACKGROUND
  Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been used for profound cardiogenic shock to bridge to decision, ventricular assist device(s) (VADs), or transplant. To assess ventricular function and volume status along with hemodynamics during ECMO weaning, we developed a standardized weaning protocol, guided by a miniaturized transesophageal echocardiography probe designed for continuous hemodynamic monitoring (hemodynamic transesophageal echocardiography [hTEE]). We reviewed our experience with this weaning protocol with hTEE guidance to assess if we could predict patient outcomes.
  
  
  METHODS
  During the academic year of 2011, hTEE-guided ECMO weaning was performed in 21 patients on VA ECMO. Left and right ventricular function and volume status were assessed by continuous hTEE, while attempting to wean ECMO after a standardized protocol. The clinical outcomes, management, and positive predictive value of the device were investigated and analyzed for this cohort of patients.
  
  
  RESULTS
  Of the 21 patients, 6 (29%) had left and right ventricular recovery and underwent optimal medical therapy or revascularization for underlying coronary artery disease; 7 (33%) had nonrecoverable left and right ventricular function; and 8 (38%) had right ventricular recovery without improvement of the left ventricular function. These 8 patients underwent left VAD placement; none subsequently developed profound right ventricular failure. The positive predictive value for ventricular recovery by hTEE was 100% using our standardized ECMO weaning protocol (95% confidence interval, 73%-100%).
  
  
  CONCLUSIONS
  The hTEE-guided ECMO weaning protocol accurately predicted the ability to wean ECMO to decision. This protocol can be applied by cardiac intensivists as a part of standard bedside intensive care unit assessment.
authors.affiliation: Department of Surgery, Thomas Jefferson University, Philadelphia, Pa.
authors.forename: Nicholas C
authors.initials: NC
authors.lastname: Cavarocchi
authors.forename: Harrison T
authors.initials: HT
authors.lastname: Pitcher
authors.forename: Qiong
authors.initials: Q
authors.lastname: Yang
authors.forename: Pawel
authors.initials: P
authors.lastname: Karbowski
authors.forename: Joseph
authors.initials: J
authors.lastname: Miessau
authors.forename: Harold M
authors.initials: HM
authors.lastname: Hastings
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Hirose
mesh_terms: D000328:Adult; D003422:Critical Care; D003661:Decision Support Techniques; D018450:Disease Progression; D017548:Echocardiography, Transesophageal / Q000295:instrumentation; D004867:Equipment Design; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D008904:Miniaturization; D008991:Monitoring, Physiologic / Q000295:instrumentation / Q000379:methods*; D019095:Point-of-Care Systems; D011237:Predictive Value of Tests; D020127:Recovery of Function; D012770:Shock, Cardiogenic / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D013318:Stroke Volume; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D016278:Ventricular Function, Right
keywords: 25.1; 27; 41.1; ECMO; ICU; LV; LVAD; RV; TTE; VA; VAD; extracorporeal membrane oxygenation; hTEE; hemodynamic transesophageal echocardiography; intensive care unit; left ventricular; left ventricular assist device; right ventricular; transthoracic echocardiography; venoarterial; ventricular assist device