Diagnostic Imaging Challenges During Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with severe cardiac and respiratory failure. However, it carries risks of complications such as thromboembolism and bleeding. Clinical monitoring requires diagnostic imaging, but challenges arise due to the complexity of care and patient transport. Contrast-enhanced computed tomography (CT) is vital in diagnosing ECMO-related complications yet it poses challenges due to hemodynamic peculiarities, especially in peripheral veno-arterial (VA ECMO), where the interaction between forward cardiac output and retrograde ECMO return may lead to flow-related artifacts in contrast distribution. Advancements in non-invasive diagnostic tools, such as transesophageal echocardiography (TEE) and bedside neuroimaging, are key to managing ECMO patients. TEE helps detect the watershed area in VA ECMO to optimize flow adjustments, while new bedside neuroimaging techniques, such as low-field magnetic resonance imaging (MRI), avoid the risk of transporting ECMO patients to radiology and improve the early detection of cerebral events. Electrical impedance tomography may also allow the bedside evaluation of patients with ARDS undergoing veno-venous (VV ECMO). Despite their enormous potential, advanced bedside diagnostic systems are not yet routine in clinical practice but represent a promising area for development. This review explores current strategies and potential advancements in optimizing diagnostic imaging protocols and non-invasive techniques, focusing on contrast-enhanced CT, bedside echocardiography, and neuroradiology.