Hemodynamics guided care during extracorporeal membrane oxygenation (ECMO): a case report

Congenital diaphragmatic hernia (CDH) represents a population of high risk of major cardiopulmonary decompensation. Maintenance of patency of the patent ductus arteriosus (PDA), using intravenous prostaglandin, is a strategy used by some clinicians to decrease the risk of right ventricular dysfunction. A term infant with CDH presented with pulmonary hypertension unresponsive to aggressive hemodynamic support. Within 12 hours of venoarterial extracorporeal membrane oxygenation (VA-ECMO) initiation, circuit chugging occurred that was refractory to multiple volume boluses. Targeted neonatal echocardiography (TnECHO) revealed a high-volume leftto-right shunt across the PDA, resulting in decreased blood return to the right atrium. Interventions aimed at reducing the left-to-right PDA shunt led to the resolution of circuit chugging. This report highlights the unique challenge of VA-ECMO flow in the setting of a large PDA and the consequences of interventions, increasing PDA diameter or lowering pulmonary vascular resistance, on the magnitude of systemic-pulmonary shunting and systemic blood flow. TnECHO played a vital role in monitoring hemodynamics and guiding ECMO adjustments.