VV vs VA ECMO Explained!

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In this lesson I take a deeper dive in to the differences between VV and VA ECMO. While these two types of ECMO are very similar in a lot of ways, they are actually quite different from each other. This is because of where the blood is return to the patient. These differences have very profound effects on the considerations and physiology of what is happening.
I start off talking about Veno-venous, or VV ECMO, going over the basics of what it is and then cover the different cannula configurations we see. This leads in to talking about recirculation, a problem exclusive to VV ECMO. From there I talk about a few different pathophysiology considerations such as oxygenation, hemodynamics and anticoagulation.
Then I move on to talk about Veno-arterial, or VA ECMO. Again I cover the basics of what it is and then talk about the various cannula configurations. The discussion on pathophysiology is more extensive and covers a wide range of topics from oxygenation, hemodynamics, non-pulsatile flow, left ventricular distention, and again anticoagulation.
Hopefully at the end of this lesson you will have a better understanding of these two types of ECMO, how they differ from one another, and some of the unique considerations when you have a patient on each type.
0:00 Intro
1:54 VV ECMO
10:41 VA ECMO
19:52 Conclusion
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Check out these other great lessons and series of lessons below!
✅ Hemodynamics: • Hemodynamic Principals
✅ Shock: • Shock
✅ ECG/EKG Rhythm Interpretation: • ECG/EKG Interpretation
✅ ICU Drips: • ICU Drips
✅ ECMO: • ECMO
✅ CRRT: • CRRT Explained!
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[@ICUAdvantage]

🎓‼ Earn CE Credits! Pre-order ICU Advantage Academy: 👉🏼 adv.icu/academy 💲 10% off Critical Care Academy (CCRN Review): 👉🏼adv.icu/cca (USE CODE "icuadv10") 💲 10% off EACH Month @ Nurisng Mastery membership: 👉🏼 adv.icu/mastery 📝 NOTES available to members! ► KZbin: adv.icu/ym | ► Patreon: adv.icu/pm Thank you guys so much for watching! Please leave a like if you enjoyed the video. I truly do appreciate it! Also I love hearing your comments so feel free to tell me what you think of the video. Also, I have a Patreon now! 😍 If you are looking for additional content 💻and more information 📝to go along with these videos, then please consider showing support over there! 👍🏼Don't forget to check me out and give us a like on Facebook & Instagram as well!

[@kiraboo5651]

Wow, this is great! I’m a SICU attending and I used this ECMO video as a review for my boards as I don’t use ECMO. Thanks so much for sharing this!

[@ICUAdvantage]

This is so awesome to hear! So happy to hear that this video was helpful for you! Thanks for taking the time to leave a comment.

[@TheAngryIntensivist]

Excellent video explaining the basics of ECMO! Thank you!

[@pamelamunoz4428]

Really enjoyed this video and appreciate the breakdown. I have now subscribed and plan on watching on the regular. Thanks.

[@nancyusher8757]

Thanks - so helpful. I am back in the cath lab…in my previous days our only cath-lab based mechanical support was an IABP. Your content really helps in understanding to troubleshoot, etc. THANK YOU. ❤

[@maratmasry]

I'm a CCU nurse about to start ECMO training. This was super helpful, thank you!

[@ICUAdvantage]

Awesome! You'll love it!

[@jessg9408]

Thank you so much for all your videos! The content is fantastic and covers all the information that my preceptor goes over. Your presentations are easy to understand and the visuals help out a lot too! This put me ahead in my orientation progression!

[@ICUAdvantage]

So cool. Really glad to hear the information was presented well and covered the stuff that you needed to know!

[@mesoob6179]

You are the best im a ccu nurse im new graduate it today i have a lecture about ecmo i got all i need by your help thank you soo much ♡

[@mhdwahoud]

Thank you so much. This video was an amazing introduction to ECMO. I found it a great refresher before my ccu rotation.

[@luvamybo0]

thank you so much for clarifying concepts that i;ve been struggling with for so long. new fan of your channel!

[@ICUAdvantage]

So amazing to hear this Amy! Happy to be able to have helped and welcome aboard! I've got a lot of great videos I think you might enjoy :)

[@kathleenpirecki528]

This is easy to follow and great to be able to review . Thank you for this module

[@ICUAdvantage]

So glad to hear that Kathleen! Thanks for letting me know!

[@megantenge85]

Can you do a video series on ABGs and different diseases or what you might expect to see? You are an extraordinary teacher and the drawings really helped to understand anatomy and physiology!! I went to nursing school 13 years ago, but have been in critical care the last year and we have been lacking classes because of Covid so thank you so much for creating these videos!!!

[@doristhecoder765]

Massively informative. This created so many connections for me. Thank you Eddie!

[@ICUAdvantage]

So glad to hear it Doris! Hope you are doing well!

[@moonschool3450]

Watching this day before my ECMO orientation.. 😅 love it!

[@mmmmmmmm1942]

Today was my first time seeing someone on ecmo. It was quite surreal. Like. Seeing this in real life is a lot different than learning about it. Very informative video! Thanks!

[@ICUAdvantage]

YES! It is truly amazing. Glad this video was in some way helpful.

[@susieli5081]

Very helpful video! Will recommend to coworkers! Thanks!

[@ICUAdvantage]

Glad you liked it Susie! Appreciate the sharing! 😊

[@navdeeptandon137]

I'm a heart failure fellow and just watched this and its absolutely amazing,keep them coming !

[@ICUAdvantage]

So awesome to hear this! Thank you so much for taking the time to leave a comment, and glad to hear you liked the video.

[@jterrusa]

Most excellent discussion. Thank you very much.

[@tonyacorbin4872]

Thanks so much for these videos. Great explanations.

[@jorgen497]

Eddie, I'm enjoying your work. I'm not a clinician but work very closely with many; particularly perfusionists. My request is a bit of a stretch: can you consider a series on CardioPulmonary Bypass? - I look forward to your next video !

[@1337sHurMaN]

Awesome video! Looking forward to the next one!

[@ICUAdvantage]

Coming soon!

[@rodrigopierami8111]

Simply the best...Thanks for sharing so much knowledge...

[@ICUAdvantage]

Thank you Rodrigo! Glad you liked it!

[@mallsri61]

It’s really Superb lecture. Don’t know how you managed to incorporate everything. But its fantastic. Both the introduction and comparison in a nut shell. I am a Consultant Anaesthetist from UK. Great job.

[@ICUAdvantage]

Thank you so much! I really appreciate you taking the time to leave such a great comment. Glad to know the video did the subject justice! 😊

[@shilohpeterson5307]

Wonderful video. The critical thinking, intelligence and dare I say the balls of the people who developed and tried these interventions for the first time is honestly quite admirable and astounding

[@ICUAdvantage]

Truly amazing!

[@user-lb2fe7pv6u]

Very informative and very much time respect so really very much efficient Much appreciated

[@rachi4346]

Excellent video!!!!!

[@vash8107]

Brilliant content. Thank you so much..

[@ICUAdvantage]

Thank you so much! Glad you liked it.

[@asmasyed3640]

This is so helpful. My dad is on VA ecmo, CRRT and a ventilator after having covid, and is waiting for a double lung and kidney transplant. Watching your video somehow eases the fear. I would love to know why might VA ecmo need support via ventilation? (first year med student just trying to understand things!)

[@ICUAdvantage]

I'm so sorry to hear about your dad Asthma. I really hope things have turned around for him since this comment. As for VA needing support from the ventilator, it all has to do with the blood that is not going through the ECMO circuit. Some still follows our normal blood flow pathway through the R side, lungs and L side of the heart. Now, depending on the amount of cardiac activity, this blood is being ejected in to the aorta and is being used to supply oxygen to the first few branches off the aorta (going to the upper body, and more importantly the head) as well as the coronaries. If the patients lungs are working great, then minimal vent settings would be needed. In theory, you could go without. But, if the function of their lungs begins to decline, we risk having desaturated vital blood supply to the brain and heart. Hope that makes sense.

[@omprak437]

t

[@user-ll3fu5go5m]

Its very usefull vedio i got meny points was not undestanding.. Thanks alot

[@ICUAdvantage]

Awesome! Glad to hear this!

[@creditrepairwizards]

QUICK ANSWER VV Lungs only VA heart and lungs The primary difference between the two is the way the ECMO circuit is connected to the patient’s circulatory system. In VV-ECMO, the circuit is connected in series to the heart and lungs, which means that it only supports the lungs 12. In contrast, VA-ECMO is connected in parallel to the heart and lungs, which means that it can support both the lungs and heart 12. Another difference between VV-ECMO and VA-ECMO is their respective indications. VV-ECMO is typically used for patients with isolated respiratory failure, while VA-ECMO is used for patients with cardiac failure or combined cardiac and respiratory failure

[@isabelsantos-case6182]

Studying for the A-CES. Listening while I bicycle. Hopefully it will sink in😊

[@ICUAdvantage]

Osmosis!

[@Drzartash]

Really good and informative 👍

[@ICUAdvantage]

Glad you liked it!

[@greatob5058]

Thank you very much !

[@ICUAdvantage]

You're welcome! 😊

[@Nadine-kw1nx]

Your videos are very educational and super helpful! Thank you! For your next ECMO video can you explain: 1. Weaning off ECMO 2. North South Syndrome 3. Causes of suctioning events 4. ECMO differences among centrimag/tandem/cardiohelp 5. Add case studies/real life scenarios ?

[@ICUAdvantage]

Great suggestion Nadine! It may be a while until I loop back around to doing more ECMO videos, but good stuff for future videos. I do discuss north south syndrome in the first lesson, "What is ECMO?" 😊

[@Nadine-kw1nx]

@@ICUAdvantage Thank you, you got yourself a subscriber and I am looking forward to your next videos.

[@TheAirsoftTech]

This is an awesome channel. I’ve already binged 4 hours of content 🤣

[@ICUAdvantage]

Haha awesome!!! Glad you like the videos and welcome aboard!

[@dr.cavidibrahimov479]

Very clear and useful;)

[@ICUAdvantage]

Glad to hear that!

[@misteratoz]

You have such a great way of looking at things in depth. Did you ever consider going to medical school and becoming a critical care attending? We need more passionate educators at that level.

[@ICUAdvantage]

Thank you so much and really glad you enjoy these lessons! At this point in life, more schooling is the last thing I want to do lol!

[@lorettalefthand8851]

I was on this ecmo I was sick with Covid 2020 but developed a blood clot on my left leg and it damaged my nerves but my nerves are coming back but slowly 😢

[@itrop9952]

My father had COPD and Heart failure isssue. Heart failure issue increased always due to Stress. My father got covid 19 and with oxygen supplement it was 76-78% saturation. As he had COPD and Stress related ( broken heart syndrome) then why they choose still ventilator instead of ECMO. When putting ventilator they forcefully some nurses and doctor also scrim at him and also my father and they bind both hand to give more stress. Within 1 hour putting ventilator he died. I was aware about ECMO but not sure what machine it was. I was all time feeling that he will be ok if that machine has been put on him. Those doctors and nurses killed my father.

[@henriquelopes9596]

Thanks.

[@ICUAdvantage]

You're welcome

[@muhammadhamdan7428]

Excellent teaching videos Please can u tell us for how many days/ weeks patient can be kept on ECMO secondly please explain how is ECMO helping in failing heart ...as it seems to increase the afterload How frequently impella is used in conjunction with ECMO for the mixing cloud phenomenon

[@laurenkrzos941]

can you do videos on other MCS devices? Your content is super helpful to a new CICU PA, btw. Thanks!! :)

[@ICUAdvantage]

Hey Lauren! I do have plans to cover more from IABP, Impella, LVAD, and probably TAH in the future. Congrats on the awesome new position btw!! Early in my career I thought I hated cardiac, but once I started working there, I found out I really loved it.

[@yasserelkenany1]

God bless you

[@ICUAdvantage]

Thank you so much!

[@trishrd1679]

This was a wonderful thorough explanation of ECMO, thank you!

[@ICUAdvantage]

Awesome! Glad you enjoyed it!

[@CaitlynN-sg9ub]

For patients with EcPella, where are the ECMO cannulas located?

[@kritibhattacharya6711]

Sir good and knowledge full video

[@ICUAdvantage]

Thank you!

[@manojedirisooriya2884]

Great talk... do you consider ECMO as a bypass or a parellel circulation ?

[@loopylou6841]

I'm just finding out about the machines that kept me alive, mine was ARDS after going into septic shock and MOF.

[@ICUAdvantage]

Wow, so sorry to hear you had that experience but really glad this was available to you. Thank you for sharing!

[@sagnikpanja2000]

Next video crrt + Ecmo or, cytosorb + Ecmo . For AKI & cytokine storm.

[@ICUAdvantage]

I am doing CRRT coming up very soon. I want to do one on the ECMO/Cytosorb combo but I want to wait until theres data back from the trial thats going on.

[@Justbeingme971]

What are the effects of a Stroke? Can a patient have a stroke that causes some loss in the hand & arm’s specifically the left arm and hand?

[@sumkindamama]

reviewing Ecmo since we have a vv ecmo covid pt.

[@ICUAdvantage]

Hope you liked it!

[@najmiusman7028]

U are amazing

[@user-ez3gv9be6o]

My father is in ecmo now, they take out one lung and is with one left, in begginng was good but some days after he got infection in the lung, now he is on ecmo treatment while trying to controll the infection. Can someone help how is this procedure, i appriciate, god be with you 🤲

[@madicrazbeanzzz]

Ima be honest here That flat line scared the pants off of me

[@emullen93]

You're a boss.

[@ICUAdvantage]

lol thanks Ethan!

[@user-er1ll2pm8e]

Character In the video It's great, I like it a lot $$

[@JanellCouture]

I do have a question about VV ecmo and anticoagulation. I think you said that we are less worried about clots post oxygenator as it will be trapped in the patients pulmonary circulation. wouldnt that increase the risk of PE or difficulty weaning?

[@ICUAdvantage]

Hey Janell! Great question. So typically the clots that form are going to be much smaller than we worry about with DVT and PEs. Yes, if they break off and lodge in the pulmonary vasculature somewhere, we are going to create a V/Q mismatch. That said, we are fully supporting them with ECMO. The body will naturally degrade the clot and eventually it will no longer cause this mismatch. Sure if the clot is large enough and we are working to trial off ECMO, this can pose a problem/delay, but in most cases this is not much of a concern. For VA ECMO though, this is a very different story even for the tiniest of fibrin and clots.

[@alexkats91]

Hi Eddy how about using ECMO (VV) or (VA) and measuring the Heart function through a Swan - Catheter? Does it gives a realistic CO?

[@ICUAdvantage]

Great question. VV ECMO should have no real impact on hemodynamics and thus your SWAN will remain true. For VA ECMO though, we are offloading the heart and returning blood after the heart. We are doing much of the role of the heart and thus the SWAN isn't going to give us accurate CO. In reality, it should be very low CO as our goal is to rest the heart.

[@unknownunknown-hn1kx]

next topic crrt pls.. cause it's new for me.. thank u

[@ICUAdvantage]

Coming VERY soon! 😊

[@unknownunknown-hn1kx]

thank u!! cause it's new in our hospital.. we don't even have a policy.. thus those nurses who are doing the crrt even don't have any clue of their responsibilities.. nor even the outcome during this procedure

[@nasatirical6185]

My son was on ECMO as a newborn. It was, and still is, the last resort.

[@PREDATOR0140]

Hi. I`m an ICU nurse for 7+ years now and our cardiothoracic surgery ICU has used ECMO for the second time.(it`s quite new technology for Romania where I practice).So we had a severe MI patient with VSD developed post MI.The surgeons managed to patch it up but he was in post op cardiogenic shock with massive amounts of epinephrine and norepinephrine and dobutamine.They decided to put him on VA ECMO as a last resort.As we are pretty new to ECMO we couldn`t figure out why the patient still needed massive amounts of pressors even thou he was on relatively high flows on ECMO.(he had femoro-femoral acces).Instead of droping the pressor rates we needed to rise them.Eventually he died.But I couldn`t figure out why it didn`t help him at all.Can you give a hint?also I would love to find out how you anticoagulate your patients on ECMO.With heparin you monitor ACT or APTT?what are the target values?(for a patient with no bleeding risc). Thank you very much!Your content is amazing!

[@ICUAdvantage]

Sounds like a disaster of a patient to care for. Unfortunately, ECMO doesn't always fix people. While you are correct in assuming that usually, especially in cariogenic shock, hypotension is a result of insufficient cardiac output, and thus when VA ECMO is started, we provide that perfusion for the patient and they should have a normal MAP. Unfortunately, other factors also go in to determining our patients perfusion and a big component of that is our vascular resistance. Given the patient sounded very sick by the time ECMO was initiated, I would image they have massive vasoplegia going on, and probably already down an irreversible path of inflammation, endothelia damage, and other factors contributing to massive vasodilation. Obviously only my guess having not been there. As for anticoagulation, we shoot for 180-200 ACT goal for VA ECMO. We often also use TEG to analyze the coagulation profile. I will say, because of the anticoagulation and general state of imbalance in the body for these sick patients, bleed in some form, is almost always an issue.

[@PREDATOR0140]

@@ICUAdvantage so you use ACT if favor of APTT? asking this because from what i red, APTT is more commonly used.We also use APTT on CRRT procedures.

[@ICUAdvantage]

@@PREDATOR0140 We have the iStat at the bedside and its quick and easy to use. We do run standard coags too but base titrations off bedside ACT.

[@neeteshagrawal37]

For vv ecmo what is the act range

[@ICUAdvantage]

It honestly truly depends. Classic anticoagulation is defined as ACT of 180-220, but oftentimes we can run with a lower goal for VV or even in some cases no anticoagulation so long as the circuit is running smoothly.

[@nematelsawy9386]

What is volume of venovenous ECMO

[@ICUAdvantage]

So it depends on which machine, the length of your tubing, etc, but for adults around 500ml generally.

[@matthewcourtney-jones6041]

will their BP drop because of the extension of the vascular circuit?

[@ICUAdvantage]

Great question Matthew. Ideally no, as the volume we remove is replaced. The tubing is all primed with fluid so as we take the blood out initially, it is immediately replaced with the same volume of fluid. That said, some patients do drop often as a reaction initially to the circuit, hence why it helps to have pressors and fluids primed and hooked up ready to go just in case.

[@matthewcourtney-jones6041]

Fascinating!

[@tenzinnnn2776]

My patient is on VA ecmo cannulated in the right fem both drainage and return. Why is her right leg only so swollen?? and the pulses still present for both.

[@ICUAdvantage]

Couple initial thoughts... 1) Are they bleeding in their leg? How have their H/H levels and MAPs been? 2) Did they use a cannula for the return or a graft? We would see this with grafts where there was so much perfusion going down the leg (opposed to flow often being restricted by the cannulas) that they would swell up. 3) Warm and swollen or cold?

[@tenzinnnn2776]

@@ICUAdvantage thanks for the quick response. The patient had been receiving daily units of prbc. Heparin turned off for 2 days due to bleeding from the insertion site. There was a feeder cannula with good flow with doppler. Leg is also warm to touch. I guess and ultrasound would help to rule out if any occlusion?

[@saullah1]

Hi, The video has given me the opportunity to learn about the different types of ECMO Intensive Care for people with lung and heart problem resulting from heart failure. Would be interested in more videos around Cardiovascular Disease and Heart Failure Videos

[@ICUAdvantage]

Hi there and glad you liked it! I do have a whole series on Heart Failure. I have a playlist with those videos. I do plan to do more cardiovascular related topics as well.

[@user-tz4nh1nm1g]

Punya

[@kurdishfaithfulofallah2228]

Hi please respond back we have a patient who is right now based on ecmo but we are not sure if he is alive or not because his eyes are full black not reacting on light.. My question is how do you know if the patient is dead and his heart is working

[@ICUAdvantage]

Sounds like brain death testing would be in order

[@shineyflipflop]

This is great, thank you. Please can you talk a bit slower? It’s complicated and I’m trying to understand and listen! I’ll have to watch a few times I think Thank you for taking the time to make these videos

[@ICUAdvantage]

Lol sorry. More often I get people saying to speed up!

[@MD-qk6si]

recirculation seems so dangerous, like it would do more harm than good

[@ICUAdvantage]

Yup! Recirculation is not a good thing. Less efficient as we can't oxygenate blood thats already oxygenated thus less "new" oxygenated blood moving forward.

[@Marie_Wang]

Thank you very much!

[@ICUAdvantage]

You're welcome Marie!