TOE for Mechanical Support 1: Balloon Pumps and ECMO copertina

TOE for Mechanical Support 1: Balloon Pumps and ECMO

TOE for Mechanical Support 1: Balloon Pumps and ECMO

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We've spent a lot of this series on machines — balloon pumps, ECMO circuits, ventricular assist devices. This episode is about the tool that makes all three of them safe. The argument is that in mechanical circulatory support, transoesophageal echo is not an investigation you order. It is part of the device. It confirms the indication, guides the cannulas in, optimises the support once it is running, and finds the complication before the patient tells you about it. And one rule runs through the whole topic: any deterioration in a patient on mechanical support gets a TOE, with specific attention to cannula malposition or occlusion. This is part one of two, covering balloon pumps and ECMO. Part two takes on assist devices and the Impella. We start with the balloon pump, where TOE has real advantages over the chest film and fluoroscopy — real-time structures, portable, no ionising radiation. Scan before you insert, for two reasons: to confirm the indication, and to exclude the absolute contraindications, which are severe aortic regurgitation, severe atheroma in the descending thoracic aorta, aortic dissection, and severe distal occlusive disease. We explain why regurgitation is so absolute — the balloon inflates in diastole to augment diastolic pressure, so a leaking valve means you drive that augmented pressure straight back into the ventricle, worsening the regurgitation without improving coronary perfusion pressure. The device fails at its own job. Then the relative contraindications, including dynamic left ventricular outflow tract obstruction, where reducing afterload makes systolic anterior motion worse. Positioning gets done properly: the tip about two centimetres distal to the origin of the left subclavian, with the proximal balloon above the diaphragm — too high and you occlude the subclavian, too low and you lose augmentation and may intermittently occlude the mesenteric or renal arteries. How to find the subclavian origin in the upper oesophageal arch short axis, how to tell the echo-dense tip and lucent balloon body from the wire, and what to use as a landmark when you genuinely cannot see the origin. Plus a technique that needs no technology at all: identify the balloon tip in the descending aorta short axis, put your fingertips on the probe at the level of the teeth, withdraw until the subclavian origin appears — and the distance your fingers have travelled is the distance from tip to subclavian. You have measured it with your hand. The ECMO section opens with the decision that matters most, which is mode — and the most useful piece of thinking in the episode. When a severe respiratory failure patient becomes haemodynamically unstable, it is usually one of four things: right ventricular dysfunction from aggressive ventilation and acutely raised pulmonary vascular resistance, ventricular dysfunction from sepsis or underlying cardiac disease, vasodilation from sepsis, or hypovolaemia. Most of those do not need arterial support. Ventilator-induced right ventricular dysfunction usually resolves once ECMO lets you drop to rest settings, and vasodilation is usually managed with VV plus vasopressors. So instability alone does not mean VA — it means work out the mechanism first, and echo is how you do that. Then what to look for before you commit: significant aortic or mitral regurgitation, which can cause acute left ventricular distension in a VA patient who is barely ejecting; severe aortic disease as a contraindication to VA; severe atheroma as a relative one, because of the sandblasting effect of the return jet; and the precise position on a PFO, which may complicate VV but is not a contraindication. Cannula positioning is laid out by configuration, because the rules are clean once you separate them — confirming the guidewire before you dilate, where the return tip belongs in VV, where the drainage tip goes for jugular–femoral versus femoral–femoral versus a double-lumen cannula, and why VA is simpler. Then recirculation: how to diagnose it with 2D and colour Doppler, the two findings that confirm it, and how to fix it under echo guidance. We finish with the complications that are hard to see coming. The specific screen appearance of left ventricular distension on VA and the two families of solution. Circuit and intracardiac thrombus. And tamponade after cardiac surgery, which is genuinely difficult because the circuit largely bypasses flow through the heart, so it is initially well tolerated and you never get the classic picture — until the right atrium collapses and your circuit flow falls. Raised central venous pressures with low circuit flows on central VA means tamponade until proven otherwise. Plus the TOE predictors associated with successful weaning from VA. Chapters (00:00) Cold open — the tool that makes the machines safe(00:50) Any deterioration on support gets a TOE(01:20) The balloon pump: why scan before you insert(02:00) Absolute contraindications, and why ...
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