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Table 1 Checklist of examinations and findings in a patient who is difficult to wean from VA ECMO support

From: The ABCDE approach to difficult weaning from venoarterial extracorporeal membrane oxygenation

Examination

Signs

Possible diagnosis

Clinical signs

Loud systolic murmur

VSR, MR, or LVOT gradient

 

Pulsus paradoxus

Cardiac tamponade

Telemetry

Bradycardia, (supra)ventricular tachycardia

Arrhythmia/conduction disorder

ECG

ST segment/T wave abnormalities

Myocardial ischemia

 

Specific arrhythmia-related signs

Arrhythmia

 

PQ interval and QRS width

Conduction disorder/dyssynchrony

Laboratory values

Troponin, CK-MB

Myocardial ischemia

 

ABG, ScVO2, SmVO2

Pulmonary gas exchange, oxygen supply, and demand balance

 

Hemoglobin levels

Oxygen supply

 

Electrolytes

Electrolyte disturbances, adrenal insufficiency

 

TSH, fT4, fT3

Thyroid dysfunction

 

CRP, PCT

Infection, inflammation

Echocardiography

RV and LV function and VTI

Impaired contractility

 

Regional wall motion abnormalities

Myocardial ischemia, dyssynchrony

 

Valvular regurgitation and its severity

Severe MR or AR

 

Dynamic pressure gradient LVOT and SAM

LVOT gradient

 

Pericardial effusion/thrombus

Cardiac tamponade

Pulmonary artery catheter

Elevated PA pressures/PVR

High RV afterload

 

Elevated CVP

Cardiac tamponade

 

Elevated CVP and PCWP

Fluid overload/decompensation

 

Significant step-up in oxygen saturation (from RA to PA)

VSR

X-ray/ CT scan

Atelectasis

RV afterload

 

Pleural effusion

Pneumonia

RV afterload

 

Pulmonary embolism

RV afterload

  1. ABG: Arterial blood gas analysis. AR: Aortic valve regurgitation. CRP: C-reactive protein. CVP: Central venous pressure. CK-MB: Creatine kinase muscle-brain fraction. MR: Mitral valve regurgitation. PCWP: Pulmonary capillary wedge pressure. RA: Right atrium. PA: Pulmonary artery. PVR: Pulmonary vascular resistance. PCT: Procalcitonin. SAM: Systolic anterior motion of the mitral valve. ScVO2: Central venous oxygen saturation. SmVO2: Mixed-venous oxygen saturation. TSH: Thyroid-stimulating hormone. fT4/ fT3: Thyroid hormones. LVOT: Left ventricular outflow tract. VTI: Velocity time integral. VSR: Ventricular septal rupture