1. Data to Delivery: The Evidence Base for VA-ECMO

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 (https://docs.google.com/forms/d/e/1FA...) . CathMasters is for educational purposes only. Music by Elijah K (https://pixabay.com/users/elijah_k-40...) from Pixabay (https://pixabay.com/music//?utm_sourc...) Pearls 1. “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). 2. 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. 3. “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. 4. 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%). 5. 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 1. 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. 1. 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 transplan...