Splanchnic ultrasound to guide unloading in VA-ECMO

Patients supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may require left ventricular (LV) unloading to prevent pulmonary congestion and adverse hemodynamic interactions. However, defining the need and timing of unloading remains challenging, as current approaches rely predominantly on cardiac and pulmonary parameters, often neglecting systemic and organ-level congestion. We report the case of a 53-year-old woman admitted with cardiogenic shock following pericardial drainage and mediastinal mass biopsy. Due to rapid hemodynamic deterioration, VA-ECMO was initiated, resulting in stabilization. Early echocardiographic assessment showed severe biventricular dysfunction but evidence of partial aortic valve opening without LV distension. To further characterize the hemodynamic profile, splanchnic Doppler ultrasound was performed, demonstrating preserved renal arterial flow (resistive index <0.72), continuous intrarenal venous flow, and low portal vein pulsatility (<30%), consistent with a non-congestive phenotype. Based on this integrated assessment, LV unloading was deferred. Subsequent pulmonary artery catheterization confirmed low filling pressures despite reduced cardiac output. A diagnosis of stress-induced cardiomyopathy was suspected, and levosimendan was administered, leading to rapid improvement in cardiac function and successful ECMO weaning. Final pathology revealed a thymic neuroendocrine carcinoma. This case highlights the limitations of relying solely on cardiac indices to guide LV unloading decisions during VA-ECMO. Splanchnic Doppler provided a non-invasive, real-time evaluation of the perfusion-congestion balance at the organ level, complementing echocardiographic and invasive hemodynamic data. The integration of multimodal monitoring may allow a more comprehensive understanding of patient-device interaction and support individualized management strategies. Further research is needed to validate the role of splanchnic ultrasound in guiding unloading decisions and optimizing outcomes in patients with cardiogenic shock supported by VA-ECMO.