CathMasters by CardioNerds cover art

CathMasters by CardioNerds

CathMasters by CardioNerds

Written by: CardioNerds
Listen for free

Welcome to CardioNerds CathMasters, the podcast dedicated to advancing interventional cardiology through high-quality, evidence-based, and experience-driven education. Featuring leading experts from across the field, CathMasters democratizes access to practical interventional cardiology knowledge for fellows, early-career operators, and experienced proceduralists alike. Hygiene & Healthy Living Music
Episodes
  • 2. Proctor’s Playbook: VA-ECMO

    2. Proctor’s Playbook: VA-ECMO
    Jun 9 2026
    CathMasters Drs. Nazli Okumus and Daniel Ambinder, along with expert faculty Drs. Ann Gage and Marwan Jumean, walk through the step-by-step procedural approach to VA-ECMO (veno-arterial extracorporeal membrane oxygenation) cannulation. Building on the Data to Delivery episode, this Proctor Playbook episode covers pre-procedural planning, cannula selection, team composition and equipment, the role of the distal perfusion cannula (DPC), decision-making on mechanical left ventricular (LV) unloading, anticoagulation dosing and timing, the cannulation procedure itself, and vascular closure strategies during decannulation. The hypothetical case continues with the 36-year-old man with fulminant myocarditis, biventricular failure, and cardiogenic shock. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes. CathMasters is for educational purposes only. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls “Cannulation for VA-ECMO is a team sport.” Success begins with pre-procedural planning: review the patient’s history, prior vascular imaging, echocardiography, invasive hemodynamics, labs, and EKG to phenotype the shock (left, right, or biventricular) and select the appropriate support configuration and cannula sizes.The distal perfusion cannula (DPC) should be the standard of care. Meta-analyses demonstrate that prophylactic DPC placement reduces limb ischemia by ~60% (OR 0.31–0.41). A practical tip from Dr. Gage: perform the antegrade SFA stick for the DPC simultaneously with the retrograde CFA stick before upsizing — this avoids the difficulty of obtaining antegrade access after a large arterial cannula is already in place.Heparin dosing at cannulation: administer an initial bolus of 50–100 U/kg of unfractionated heparin (UFH) after access but before dilation. For a 70 kg patient, this is approximately 5,000 units. Maintain anticoagulation with a UFH infusion targeting ACT 180–220 seconds, aPTT 1.5–2.5× baseline, or anti-Xa 0.3–0.7 IU/mL.Consider upsizing the dilator 1–2 French above the intended cannula size (e.g., dilate to 27F for a 25F venous cannula) to facilitate smooth cannula insertion. Dr. Jumean’s pro tip: after removing the dilator, check wire movement before advancing the cannula — a kinked wire during dilation is a preventable but dangerous complication.Percutaneous decannulation is an evolving and viable alternative to surgical cutdown. Pre-closing at the time of cannulation (two Perclose ProGlide devices per site) enables percutaneous explantation with technical success rates of 91–95% and lower groin infection rates compared with surgical cutdown. Notes Pre-Procedural Planning VA-ECMO cannulation requires significant pre-planning and coordination, even when time is limited. The operator should review all primary data with the team before proceeding.Key data to review: Echocardiography: Biventricular function, valvular disease (especially aortic insufficiency and mitral regurgitation), wall motion abnormalities, and chamber sizes. Echo also helps refine the differential diagnosis (e.g., regional wall motion abnormalities suggest CAD; flail mitral leaflet suggests delayed MI complication).Invasive hemodynamics (PA catheter): Phenotype the shock as left-dominant, right-dominant, or biventricular. This determines the support configuration (VA-ECMO alone vs. VA-ECMO + LV unloading vs. VAV-ECMO for additional oxygenation).Prior vascular imaging: Review prior angiograms or CT scans of the femoral/iliac vessels to assess vessel size, tortuosity, calcification, and PAD. This informs cannula sizing and access strategy.EKG and labs: Confirm diagnosis, assess for arrhythmias, and evaluate organ function (renal, hepatic, coagulation). Dr. Gage’s program uses a formal ECMO timeout before cannulation — a checklist that reviews indications, contraindications, equipment, and team roles. Equipment and Team Team composition: Cannulating operator (interventional cardiologist, cardiac surgeon, or critical care physician), assistant (fellow or second operator), perfusionist (to prime and manage the circuit), ICU or cath lab nurse, and a cardiac surgeon aware and available as backup.The equipment cart should include: Vascular access kit with micropuncture needles and sheathsA stiff guidewire Sequential dilatorsVenous cannula: 23–25F multi-stage (most common); 21F may be used in smaller patients. Flow through the circuit is primarily determined by the venous drainage cannula size.Arterial cannula: 15–20F single-stage, selected based on patient body size and vessel diameter. There is a trend toward smaller arterial cannulas (15–17F) to minimize bleeding and ischemic complications and facilitate percutaneous removal. The vessel should ideally be 1–2 mm larger than the cannula to reduce limb ischemia risk.Distal perfusion cannula: 5–8F antegrade sheath for the SFA or retrograde via the posterior ...
    Show More Show Less
    10 mins
  • 1. Data to Delivery: The Evidence Base for VA-ECMO

    1. Data to Delivery: The Evidence Base for VA-ECMO
    Jun 9 2026
    In this episode, CathMasters hosts Drs. Nazli Okumus and Daniel Ambinder, joined by expert faculty Drs. Ann Gage and Marwan Jumean, examine the foundational principles of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Utilizing a case study of a 36-year-old patient with fulminant myocarditis and biventricular failure, the panel analyzes the VA-ECMO circuit’s anatomy, clinical indications and contraindications, and the supporting evidence across various shock etiologies. The discussion also covers the debate over left ventricular (LV) unloading, the vital function of multidisciplinary shock teams, and strategies for informed consent and family counseling. This episode serves as an introduction to future discussions on cannulation techniques and complication management. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes. Contribute to CathMasters by submitting your case for CathConference HERE. CathMasters is for educational purposes only. Music by Elijah K from Pixabay Pearls “ECMO is an egotistical machine.” Inflow and outflow are referenced from the perspective of the ECMO circuit — inflow = blood entering the machine (venous/drainage cannula); outflow = blood leaving the machine (arterial/return cannula).VA-ECMO is the only temporary mechanical circulatory support (MCS) device that provides both full circulatory and respiratory support — making it uniquely suited for biventricular failure with concomitant hypoxemia, as in fulminant myocarditis.“VA-ECMO increases LV afterload” — but the hemodynamic story is more nuanced. The venous drainage cannula reduces right-sided preload, which may decrease LV filling and partially counterbalance the increase in afterload. Not every patient requires mechanical LV unloading; the loading conditions and contractility of both ventricles must be considered.Randomized controlled trial data for VA-ECMO in cardiogenic shock (ECLS-SHOCK, ECMO-CS) have been neutral. However, underlying diagnosis matters: survival is highest in fulminant myocarditis (~65%) and primary graft failure, and lowest in postcardiotomy shock (mortality ~65–75%).Shock teams improve outcomes. Multicenter data demonstrate that centers with shock teams have ~28% lower adjusted odds of cardiac ICU (CICU) mortality (adjusted OR 0.72), driven by earlier recognition, increased pulmonary artery catheter (PAC) use, and more appropriate deployment of MCS. Notes Anatomy of the VA-ECMO Circuit ECMO = Extracorporeal Membrane Oxygenation. VA-ECMO does the work of both the heart and the lungs — it provides full circulatory support and gas exchange, normalizing pCO2, pO2, and pH.The circuit is the complete path blood travels from venous drainage to arterial return. Deoxygenated blood is drained via a large-bore venous cannula → centrifugal pump → membrane oxygenator (gas exchange) → oxygenated blood returned via a large-bore arterial cannula.The two cannulas have three interchangeable naming conventions: Venous/Arterial, Inflow/Outflow (relative to the machine), or Drainage/Return (relative to the patient).Peripheral VA-ECMO is placed percutaneously (Seldinger technique), often by an interventional cardiologist, surgeon, or critical care physician. The most common configuration is femoro-femoral: venous cannula tip at the SVC-RA junction, arterial cannula tip in the descending aorta. Alternatives include IJ venous/axillary arterial, or percutaneous left atrial VA-ECMO via transseptal cannulation (e.g., TandemHeart system or multi-stage cannula).Central VA-ECMO requires surgical anastomosis to intrathoracic vessels; most commonly used in postcardiotomy patients.A distal perfusion cannula (typically 5F–8F) is placed in the superficial femoral artery (SFA) to prevent limb ischemia. Indications and Contraindications for VA-ECMO VA-ECMO is indicated for acute, potentially reversible cardiac or cardiopulmonary failure when conventional therapies have failed. It serves as a bridge to recovery, a bridge to decision, or a bridge to advanced therapies (durable VAD or heart transplant).Indications: Cardiogenic shock (CS): AMI, fulminant myocarditis, acute decompensated biventricular HF, postcardiotomy shock, cardiac transplant primary graft failure, arrhythmic storm, drug overdose/cardiotoxicityMassive pulmonary embolism (PE): Bridge to thrombectomy or thrombolysisExtracorporeal cardiopulmonary resuscitation (ECPR): Refractory cardiac arrestProcedural support: High-risk PCI or structural procedures Contraindications: Relative: Contraindication to systemic anticoagulation, severe PAD limiting peripheral access (central cannulation may be considered), aortic dissection, significant aortic insufficiencyAbsolute: Comfort-focused goals of care, irreversible neurological catastrophe, conditions incompatible with recovery, limited life expectancy (e.g., end-stage malignancy), established irreversible multi-organ failure Data for VA-ECMO Across...
    Show More Show Less
    24 mins
  • Introducing: CardioNerds CathMasters – The Interventional Cardiology Podcast

    Introducing: CardioNerds CathMasters – The Interventional Cardiology Podcast
    Jun 7 2026

    In this inaugural episode of CardioNerds CathMasters, co-founders Dr. Amit Goyal and Dr. Daniel Ambinder introduce a new podcast dedicated to democratizing interventional cardiology (IC) education. Recognizing the need for high-quality, evidence-based, and experience-driven content tailored to the busy, technically advanced proceduralist, the hosts launch this series to foster lifelong learning. The episode outlines the core mission of CathMasters and introduces five recurring episode formats: Data to Delivery, Proctor Playbook, Crisis Control, Cath Conference, and Beyond the Lab. Drs. Goyal and Ambinder invite the global interventional community to engage, collaborate, and contribute, emphasizing that collective experience and a commitment to growth are essential to advancing the field of interventional cardiology.

    Contribute to CathMasters by submitting your case for CathConference HERE.

    CathMasters is for educational purposes only. Music by Elijah K from Pixabay
    Show More Show Less
    6 mins
adbl_web_anon_alc_button_suppression_t1
No reviews yet