Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO)

Modalities of Extracorporeal Life Support (ECLS)

  • Cardiopulmonary Bypass (CPB) (see Cardiopulmonary Bypass, [[Cardiopulmonary Bypass]])
  • Extracorporeal CO2 Removal (ECCO2R): originally developed by Gattinoni (JAMA, 1986) [MEDLINE]
  • Extracorporeal Membrane Oxygenation (ECMO)
    • Venovenous Extracorporeal Membrane Oxygenation (VV-ECMO) (see Venovenous Extracorporeal Membrane Oxygenation, [[Venovenous Extracorporeal Membrane Oxygenation]])
    • Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) (Percutaneous Cardiopulmonary Support, CPS)

Differences Between Cardiopulmonary Bypass and Extracorporeal Membrane Oxygenation (ECMO) (see Cardiopulmonary Bypass, [[Cardiopulmonary Bypass]])

  • Cardiopulmonary Bypass is Equipped with Reservoir Into Which Blood from the Heart is Drained: allows a bloodless surgical field for valve and aortic operations
    • In Contrast, the ECMO Circuit Does Not Contain a Reservoir, So Blood Flow Needs to Be Continuous
  • Cardiopulmonary Bypass Can Be Utilized in Conjunction with Air Vent Tubing, Cardioplegia Line for Myocardial Preservation, or Cell Salvage Tubing
  • Requirement for Systemic Heparin Anticoagulation is Less Intense for ECMO Because Blood Flow is Continuous and There is No Blood-Air Interface in the Reservoir
    • Higher Flow Rates of >4 L/min are Used During ECMO (in Contrast to the Lower Flow Rates of 2 L/min Used During CPB)
    • However, Continuous Anticoagulation is Necessary to Prevent Thrombus Formation on the Synthetic Thrombogenic Surfaces of Both CPB and ECMO
  • ECMO Circuits are Designed for Longer-Term Use (May Be Used for Weeks, Depending on the Life of the Membrane Oxygenator), While CPB Use is Designed for Use for a Period of Hours


General Comments

  • Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) Provides Both Respiratory and Hemodynamic Support (see Cardiac Assist Devices, [[Cardiac Assist Devices]]): VA-ECMO does not depend on the patient’s intrinsic cardiac output
    • Provides full cardiopulmonary support (hemodynamic support + oxygenation of venous blood) analogous to that provided by cardiopulmonary bypass during cardiac surgery
  • Mainly Used in the Cardiac Catheterization Laboratory: mainly due to the requisite delay between the acute event and achievement of full cardiopulmonary support

Cardiac Arrest (see Cardiac Arrest, [[Cardiac Arrest]])

  • General Comments: use of VA-ECMO is the setting of refractory cardiac arrest has been termed “eCPR”
  • Etiology

Refractory Cardiogenic Shock (see Cardiogenic Shock, [[Cardiogenic Shock]])


  • Acute Myocardial Infarction (see Cardiogenic Shock, [[Cardiogenic Shock]])
  • Congestive Heart Failure (CHF) (see Congestive Heart Failure, [[Congestive Heart Failure]])
  • Drug Intoxication
  • Fulminant Myocarditis (see Myocarditis, [[Myocarditis]])
  • Intractable Arrhythmias
  • Post-Cardiotomy Cardiac Failure

Clinical Efficacy

  • Cochrane Review of VV-ECMO and VA-ECMO in Critically Ill Adults (Cochrane Database Syst Rev, 2015) [MEDLINE]
    • xxxx

High-Risk Percutaneous Transluminal Coronary Angioplasty (PTCA)

  • May be inserted prophylactically or as required for high-risk procedures

Refractory Cardiovascular Dysfunction Associated with Septic Shock

  • Clinical Efficacy
    • Small Trial of VA-ECMO in Refractory Septic Shock (Critical Care Med, 2013) [MEDLINE]: small study of 14 patients
      • VA-ECMO Rescued 70% of Patients in this Small Study

Pulmonary Hypertension (see Pulmonary Hypertension, [[Pulmonary Hypertension]])

  • Clinical Efficacy
    • Small Study of VA-ECMO as a Bridge to Transplant in Non-Ventilated Patients with Pulmonary Hypertension (Am J Transplant, 2010) [MEDLINE]
      • VA-ECMO May Be Feasible as a Bridge to Transplant in Non-Ventilated Patients with Pulmonary Hypertension



  • Unrecoverable Cardiac Function in a Patient Who is Not a Candidate for Cardiac Transplant or LVAD


  • Aortic Dissection (see Aortic Dissection, [[Aortic Dissection]])
  • Coagulopathy (see Coagulopathy, [[Coagulopathy]])
  • Contraindication to Anticoagulation
    • Active Hemorrhage: although in patients with severe bleeding, anticoagulation can be held for limited periods of time
    • Intracerebral Hemorrhage
    • Recent Surgery
  • Mechanical Ventilation >7-10 Days
  • Multiorgan Failure
  • Recent Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]])
  • Recent Head Trauma (see Traumatic Brain Injury, [[Traumatic Brain Injury]])
  • Severe Peripheral Vascular (Artery) Disease (see Peripheral Vascular Disease, [[Peripheral Vascular Disease]])
  • Severe Aortic Insufficiency (AI) (see Aortic Insufficiency, [[Aortic Insufficiency]])
  • Uncontrolled Sepsis (see Sepsis, [[Sepsis]])



  • General Comments
    • Pump Characteristics: pumps can usually generate up to 8-10 L/min of flow (with flow rates being generally limited by venous preload and cannula size)
    • Requirement for Continuous Technical Support (On-Site Perfusionist)
    • Duration of Use: may be used for up to 30 days
  • Systems
    • Bard Cardiopulmonary Support (CPS): requires placement of large bore catheters with tips positioned in the aorta and right atrium
      • Blood from the venous catheter is pumped through a heat exchanger/oxygenator and returned to the systemic arterial circulation via the arterial cannula
    • MagLev Centrifugal Pump in Combination with Long-Term Oxygenators (CentraMag plus Maquet Quadrox)
    • Maquet CardioHelp
    • Maquet Rotaflow
      • Duration of Use: XXXXX

Vascular Access

  • Venous Catheter in Inferior Vena Cava or Right Atrium (Long Catheter): venous blood is removed from the patient
  • Arterial Catheter in Femoral Artery (Short Catheter): oxygenated blood is delivered retrograde up the descending aorta and into the ascending aorta to assure delivery to the coronary arteries and great vessels
    • If the Left Ventricular Cardiac Output is Negligible: the required extracorporeal flow will be low
    • As the Left Ventricular Cardiac Output Recovers and Cardiac Output Increases: the required extracorporeal flow will need to increase
      • In this case, anterograde aortic flow will compete with retrograde flow from the femoral arterial cannula, and a mixing zone of anterograde deoxygenated (in patients with respiratory failure) and retrograde oxygenated blood flow will occur: the flow required to assure that this mixing zone remains in the ascending aorta will increase as the native CO increases
      • Monitoring pulse oximetry from the right upper extremity or arterial blood gases from the right radial artery will elucidate whether VA-ECMO is providing adequate cerebral (although not necessarily cardiac) oxygenation



  • Heparin Drip (see Heparin, [[Heparin]])


  • VA-ECMO Blood Flow Rate (Red Arrow in Photograph Denotes the RPM with the Flow Rate Adjacent to It)

Adverse Effects/Complications

Complications Directly Related to the ECMO Circuit (NEJM, 2011) [MEDLINE]

  • Cannula-Related Problems
  • Disseminated Intravascular Coagulation (DIC) (see Disseminated Intravascular Coagulation, [[Disseminated Intravascular Coagulation]])
  • Hemolysis (see Hemolytic Anemia, [[Hemolytic Anemia]]): accounts for 6.9% of adverse events
  • Hemorrhage: most common complication (occurs in 34% of cases)
  • Infection (Related to or Unrelated to ECMO)
  • Ischemic Cerebrovascular Accident (CVA) (see Ischemic Cerebrovascular Accident, [[Ischemic Cerebrovascular Accident]]): stroke rates have been reported to be as high as 8% (Crit Care Med, 2008) [MEDLINE]
  • Local Arterial or Venous Complications: improving technique has decreased the vascular complication rate to approximately 1.4% of cases
    • Lower Limb Ischemia (see Acute Limb Ischemia, [[Acute Limb Ischemia]]): this risk can decreased by using a small anterograde perfusion cannula in the supercial femoral artery, to perfuse the leg distal to the femoral arterial cannula
  • Other Mechanical Complications
  • Oxygenator Failure
  • Thrombosis: second most common complication (occurs in 17% of cases)
    • Thrombosis in Oxygenator
    • Thrombosis in Other Circuit
  • Thrombocytopenia (see Thrombocytopenia, [[Thrombocytopenia]])
    • Epidemiology: common
    • Physiology
      • Heparin-Induced Thrombocytopenia (HIT) (see Heparin-Induced Thrombocytopenia, [[Heparin-Induced Thrombocytopenia]])
      • Platelet Consumption in ECMO Circuit: due to fibrin stranding in oxygenator


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  • Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA. 1986;256(7):881-886 [MEDLINE]
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