Form Of Mechanical Circulatory Support Research Articles

Current status and future directions in pediatric ventricular assist device.

A ventricular assist device (VAD) is a form of mechanical circulatory support that uses a mechanical pump to partially or fully take over the function of a failed heart. In recent decades, the VAD has become a crucial option in the treatment of end-stage heart failure in adult patients. However, due to the lack of suitable devices and more complicated patient profiles, this therapeutic approach is still not widely used for pediatric populations. This article reviews the clinically available devices, adverse events, and future directions of design and implementation in pediatric VADs.

Abstract 15552: Augmentation of Right Ventricular Strain Dynamics During Direct Mechanical Ventricular Actuation

Introduction: Available forms of mechanical circulatory support are associated with significant complications related to blood contact. Direct cardiac compression (DCC) devices avoid blood contact but may impair diastolic function. This derogatory effect of DCC devices may be related to a negative impact on RV function. Direct mechanical ventricular actuation (DMVA) uniquely augments LV diastolic function. The purpose of this study was to evaluate DMVA’s effect on RV function. Methods: Ischemic heart failure (HF) was induced using 5 mins of ventricular fibrillation (VF) circulatory arrest in large mature canines (n=9). Hearts were defibrillated and DMVA applied for 15 mins. VF circulatory arrest was subsequently re-induced for 5 mins to generate progressive HF. The experimental protocol was continued for 3 hrs. Intracardiac echocardiography was used to quantify longitudinal strain and peak strain rates in the RV and LV using speckle-tracking algorithms. Two-way ANOVA with Tukey HSD tests were used to evaluate statistical differences in strain metrics (baseline vs. HF vs. DMVA support and LV vs. RV). Results: DMVA increased RV fractional area change (DMVA: 0.282 ± 0.011, Mean ± SEM) relative to either baseline (0.221 ± 0.15, p=0.004) or HF (0.170 ± 0.006, p<0.001). DMVA statistically significantly augmented all RV strain metrics relative to either baseline or HF (Table). Additionally, all DMVA strain metrics were statistically significantly greater in the RV than the LV (LV strain: 18.8 ± 0.5 %, p<0.001, LV strain rate: systolic, -1.46 ± 0.04 1/s, p<0.001, diastolic, 1.51 ± 0.04 1/s, p<0.001). Conclusions: DMVA substantially improved RV strain dynamics compared to baseline or HF in this model. During DMVA support, strain dynamics in the RV were amplified more than the LV. This RV augmentation is important to achieving balanced biventricular DMVA support. Enhanced diastolic RV and LV augmentation during DMVA remains highly unique when compared to any other devices.

Abstract 16172: Impella Use in Large Post-Infarct Ventricular Septal Rupture

Background: Ventricular Septal Rupture (VSR) is a deleterious complication associated with myocardial infarction (MI). The most common form of mechanical circulatory support (MCS) utilized in post-MI complications is intra-aortic balloon pump (IABP). Impella is a far less commonly used modality as there is the potential for right-to-left shunting and a chance of mechanical perforation of the heart. Below is a case where an Impella 5.5 catheter was necessary to bridge a patient for surgical repair. Case presentation: A 76-year-old male patient presented to an outside hospital with an acute inferior ST-elevation myocardial infarction. He was treated with thrombolysis and was emergently taken to the catheterization lab where he underwent stenting of his RCA with plan to medically manage his non-culprit disease. His hospital course was complicated by cardiogenic shock with an echocardiogram that demonstrated a large VSR (Figure 1). A right heart catheterization demonstrated a significant left-to-right shunt (Qp/Qs ratio of 6:1) which necessitated mechanical support with an IABP as per standard of care. Post-IABP his Qp/Qs ratio improved to 1.6:1 but he continued to be under supported and remained in cardiogenic shock. Surgical repair of the VSR was planned for 1-week post-MI so he was transitioned to an Impella 5.5 catheter in order to stabilize and bridge him for surgery. Patient underwent surgical VSR repair and CABG on hospital day 7. Post-op he did well and was later discharged to rehabilitation center with subsequent recovery. Conclusions: If properly managed, utilization of an Impella catheter can be an effective tool to stabilize patients in post-MI VSR with refractory cardiogenic shock and bridge patients towards surgical repair. It is particularly effective when additional MCS support is required beyond the contemporary IABP and it can be used to stabilize patients for longer durations to ultimately avoid emergent surgery.

The Year in Coagulation and Transfusion: Selected Highlights from 2022

This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.

Incidence and Predictors of Acute Limb Ischemia in Patients With Acute Myocardial Infarction—Insight from National Readmission Database

Acute limb ischemia (ALI) has been a rare complication of acute myocardial infarction (AMI), however, with the increasing use of mechanical circulatory devices it is seen more frequently. The incidence and predictors of ALI in patients with AMI in contemporary clinical practice are unknown. A retrospective review of patients with index hospitalization for AMI in the Nationwide Readmission Database from 2016 to 2019 was done. We evaluated the annual incidence of ALI and its impact on outcomes. We used multivariate logistic regression analysis to determine predictors of ALI. In 1,283,586 patients with AMI, 3,971 patients (0.31%) had ALI and 365 (0.03%) had limb amputation. The 3 major predictors of ALI were peripheral artery disease (odds ratio [OR] 11.91, 95% confidence interval [CI]: 10.78 to 13.51), intravascular microaxial left ventricular assist device (OR 4.39, 95% CI 3.86 to 5.00), and veno-arterial extracorporeal membrane oxygenation (OR 4.37, 95% CI 3.19 to 6.01). Intra-aortic balloon pump had a substantially lower predictive ability (OR 1.81, 95% CI 1.63 to 2.0, p<0.0001) than other forms of mechanical circulatory support. The mortality rate in patients with ALI was significantly higher than those without ALI (19.49% vs 4.85%, p<0.0001). Patients who developed ALI had higher rates of amputation (1.59% vs 0.02%, p<0.0001). This observational nationwide study showed that ALI is an important complication in patients with AMI and is more frequently seen in patients who have peripheral artery disease, and require a left ventricular assist device or venoarterial extracorporeal membrane oxygenation. This complication was also associated with significantly higher in-hospital mortality.

177: SAFETY AND EFFECTIVENESS OF AN ANTI-XA-BASED UNFRACTIONATED HEPARIN PROTOCOL FOR IMPELLA DEVICES

Introduction: Impella® devices are used as a short-term form of mechanical circulatory support in patients with cardiogenic shock or high-risk percutaneous coronary intervention (PCI). Anticoagulation protocols in this population are not well established. The purpose of this study was to evaluate thrombotic and bleeding complications when using an unfractionated heparin (UFH) protocol with a reduced initial dose of 6 units/kg/hour targeting an anti-Xa goal of 0.3-0.5 units/mL. Methods: This single-center, retrospective study included patients on Impella® support who received an UFH purge solution and/or an intravenous UFH infusion. The primary outcome was overall composite bleeding including major or minor bleeding or bleeding requiring medical attention. Secondary outcomes included thrombotic events and systemic UFH exposure. Results: Forty-one patients met criteria for inclusion. Anti-Xa values were in therapeutic range 46% of the time while on Impella support (interquartile range 16.6-75), with a median IV UFH dose of 6 units/kg/hour. The overall bleeding rate was 29.2% (12 total events), of which six were minor bleeds and two were major bleeds. Rates of thrombosis were low with two events during the study period. Conclusions: Use of a modified UFH protocol to target an anti-Xa goal of 0.3-0.5 units/mL prevented thromboembolic events, demonstrating the efficacy of this strategy. The majority of bleeding events were minor with no cases of fatal bleeding or intracranial hemorrhage. Based on this study, an anti-Xa goal of 0.3-0.5 units/mL with an initial rate of 6 units/kg/hr may be a useful approach to minimize heparin exposure while preventing thrombotic complications.

Use of cardiopulmonary bypass machine in intensive care unit as a short term mechanical circulatory support for recovery of cardiac function.

Extracorporeal Membrane Oxygenation (ECMO) is used as a bridge to recovery of cardiac function following completion of congenital cardiac surgeries where there is failure to wean from cardiopulmonary bypass (CPB) or severe low cardiac output states in the post operative periods. Although ECMO is a well-established form of mechanical circulatory support, the associated cost can be a huge financial burden on families. We are an ECMO center and use the same in post operative congenital cardiac surgeries for mechanical cardiovascular support if needed. However, a significant proportion of the children, whom we operate, are funded by government aides. The resources are limited in such circumstances. If needed, we use the same CPB circuit and cannulae used in the Operating Room (OR) and support them at a significantly lower cost compared to ECMO. We report our experience of using conventional CPB machine as a short-term bridge to recovery of cardiac function in Intensive Care Unit where there was limitation of funds. Essentially same CPB circuit with roller pump is retained, by omitting cardiotomy suckers. We use D901 Lilliput 1 Oxygenator (Sorin, Italy) for children <5kg and D902 Lilliput 2 (Sorin, Italy) Oxygenator for children >5Kg. We supported nine patients on CPB between March 2019 and December 2021. During this time, 1392 congenital cardiac surgeries were performed. We could wean off three patients (33.3%) and discharge two patients (22.2%). Our support time ranged from 21h to 60h with a median of 48h. Beyond 48h of support, we experienced several CPB induced complications in our cohort. In resource-limited settings, conventional CPB machines can be used for short-term cardiac support. Although results may not be comparable to using ECMO, some patients can be definitely salvaged, who would otherwise die in the absence of institution of mechanical circulatory support.

Numerical simulation of the leakage flow of the hydrodynamically levitated centrifugal blood pump for extracorporeal mechanical circulatory support systems.

Extracorporeal centrifugal pumps are widely used in various forms of mechanical circulatory support, including extracorporeal membrane oxygenation and ventricular assist device. A durable centrifugal pump was developed by implementing a new hydrodynamic bearing design that prevents the impeller from touching to the casing wall and provides sufficient washout through the pump to prevent thrombus formation in the pump. The hydrodynamic bearings of the pump are composed of dual annular paths located on both sides of the impeller. Computational fluid dynamics analyses were performed on the flow field inside the pump to estimate the leakage flow through the gap and its impact on the pump efficiency and biocompatibility. The calculations were performed for motor speeds from 3000 to 5000rpm and flow rates from 1.0 to 9.0L/min. The leakage flow increased linearly with increasing pressure head of the pump, and the total leakage flow ranged from 2.0 to 27.3% of the total flow. The average wall shear stresses in the casing bottom ranged from 10.6 to 40.9Pa. The leakage flow of the centrifugal pump with the hydrodynamically levitated impeller had a measurable impact on hydraulic energy losses while enhancing the washout flow to achieve good anti-thrombogenicity.

Trends In The Use Of Va-ecmo In The Management Of Post Infarction Ventricular Septal Defect

<h3>Introduction</h3> Myocardial infarction resulting in a post-infarction ventricular septal defect (PIVSD) is an infrequent but detrimental event resulting in high morbidity and mortality rates. This complication can be particularly devastating in the setting of cardiogenic shock, which can complicate definitive surgical or transcatheter treatment of the condition. Veno-Arterial Extra-Corporeal Membrane Oxygenation (VA-ECMO) is a form of mechanical circulatory support that can be used to support such patients and guide decisions on definitive therapy. Our study aimed to assess the role of VA-ECMO in management of patients with PIVSD. <h3>Methods</h3> Data in the form of ELSO variables was requested from the Extra Corporeal Life Support Organization (ELSO) registry. The study period was from year 2000 to 2018. Inclusion criteria were a diagnosis of Ventricular septal defect as current complication following acute myocardial infarction, VA ECMO, and age 18-100. Exclusion criteria were VV ECMO, Age less than 18 years old, and Non-VSD. <h3>Results</h3> 189 patients met study criteria. 28%(n=53) patients were female, and the median age was 63 years. In terms of race, 72%(n=136) were white,8% (n=16) were Asian, 6% (n=12) were Hispanic and 2% (n=4) were Black. 30% patients (n= 57) were reported to be alive at discharge. <h3>Conclusion</h3> VA-ECMO can be used to support patients with Post Infarction Ventricular Septal Defect. This condition continues to have a high mortality rate with 30% survival noted in our study. There was poor representation of females and racial minorities in the study population.

Impella Management for the Cardiac Intensivist.

The Impella mechanical circulatory support (MCS) system is a catheter-based continuous flow cardiac assist device that is widely used in the treatment of cardiogenic shock in medical and surgical cardiac intensive care units. As with all forms of MCS, device-related complications remain a major concern, the incidence of which can be mitigated by adhering to a few fundamental concepts in device management. The purpose of this review is to comprehensively describe our strategy for managing, repositioning, and weaning the Impella catheter.

Anticoagulation in syncardia total artificial heart recipients: anti-factor Xa or activated partial thromboplastin time?

Although the activated partial thromboplastin time (aPTT) has historically been the method of choice for anticoagulation monitoring in patients undergoing mechanical circulatory support with intravenous unfractionated heparin, it is being progressively superseded by the anti-factor Xa (anti-Xa) method. A retrospective single-arm, single-centre analysis of 20 patients who underwent total artificial heart implantation entailed simultaneous determinations of aPTT and anti-Xa. Agreement between these parameters was assessed using the Bland–Altman method. Despite a positive correlation between aPTT and anti-Xa, normal target ranges were poorly aligned: from 5th to 30th postoperative day, for anti-Xa values of 0.2 and 0.4 U/ml corresponding aPTT values were 52.1 and 65.2 s, 7.9 and 14.8 lower than predicted values, respectively. This was not associated with thromboembolic sequalae. It was not possible to demonstrate a significant relationship between the predictor variables (postoperative day; white blood cell count; C-reactive protein concentration; alanine transaminase and alkaline phosphatase level; bilirubin; haemoglobin; albumin and total protein concentration) and the agreement between aPTT and anti-Xa levels. In summary, when anti-Xa levels were used to guide anticoagulation therapy, corresponding aPTT levels were low with respect to target range. Methodology applied in this study is generalizable to other forms of mechanical circulatory support.

Theoretical considerations for a left atrial pump in heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) is a heterogenous group of disorders, unified by findings of elevated left atrial and left ventricular filling pressures in the setting of normal systolic function. Medical therapies for HFpEF patients are markedly limited, and these patients are often unable to tolerate conventional left ventricular assist device therapies because of small chamber size. The Synergy System (CircuLite, Inc., Saddle Brook, NJ) was a micropump-based form of mechanical circulatory support in which flow derived from the left atrium wasdelivered to the subclavian artery. In this review, we discuss the potential role of the Synergy left atrial pump to address the hemodynamic derangements of HFpEF.

Effect of the New Donor Heart Allocation System on Waitlist Mortality among All Candidates Listed with Mechanical Circulatory Support

<h3>Purpose</h3> To evaluate the effect of the new donor heart allocation system on candidate waitlist morbidity and mortality in those listed with mechanical circulatory support (MCS). <h3>Methods</h3> The United Network for Organ Sharing (UNOS) database was queried for adults (≥18) listed for heart transplantation between October 2015 and September 2019. Candidates who were listed with any form of mechanical circulatory support (MCS) (intraaortic balloon pump (IABP), extracorporeal membrane oxygenation (ECMO), durable left ventricular assist device (LVAD), and others) were included. Candidates who did not have MCS at the time of listing or were listed between October 2017 and October 2018, were excluded to prevent inclusion of candidates who were listed under the old system and transplanted under the new system. <h3>Results</h3> Of the 4175 candidates included in this study, 2784 (66.7%) and 1391 (33.3%) were listed under the old and new system, respectively. Mean age and body mass index were similar, although candidates were slightly more likely to be female under the new system (23.0 vs. 20.4%, <i>p</i>=0.05). The proportion of inotrope-dependent candidates was significantly higher under the new system (24.4 vs. 18.5%, <i>p</i><0.01) although ventilator dependence did not differ significantly (4.0 vs. 3.6%, <i>p</i>=0.52). The distribution of MCS present at listing changed significantly as follows: IABP: +14.5%; ECMO: +2.1%; durable LVAD: -15.9%; and other: -0.7% (<i>p</i><0.01). Candidates listed under the new allocation were significantly less likely to experience death or worsening clinical condition on the waitlist (adjusted HR 0.61, 95% CI 0.47-0.78, <i>p</i><0.01) (Figure). <h3>Conclusion</h3> Candidates listed with MCS under the new donor heart allocation system experience less waitlist mortality. With regard to all candidates supported by MCS, the new system has achieved its goal.

Agreement between Anti-Factor Xa and Activated Partial Thromboplastin Time Measurements in Syncardia Total Artificial Heart Recipients Receiving Postoperative Anticoagulation with Unfractionated Heparin

<h3>Purpose</h3> The Activated Partial Thromboplastin Time (aPTT) has been the historical method of choice for anticoagulation monitoring in patients undergoing mechanical circulatory support with intravenous unfractionated heparin (IVUFH). However, the assay is susceptible to interference effects and is being progressively superseded by the anti-Factor Xa (anti-Xa) method. The study aim was to investigate the agreement between aPTT and anti-Xa measurements in patients receiving post-operative anticoagulation with IVUFH following Syncardia Inc. Total Artificial Heart (TAH) implantation. <h3>Methods</h3> A retrospective single arm, single centre analysis of 20 patients who underwent TAH implantation from July 2014 to October 2018 entailed simultaneous determinations of aPTT and anti-Xa. Agreement between these parameters was assessed using a novel statistical approach based on the Bland-Altman method. <h3>Results</h3> In spite of a positive correlation between aPPT and anti-Xa measurements, normal target ranges were poorly aligned: from 5^th to 30^th post-operative day, for anti-Xa values of 0.2 and 0.4 U/mL corresponding APTT values were 51.1 and 64.3 seconds, respectively. Moreover, white blood cell count was associated with a trend towards lower aPTT levels with respect to anti-Xa. Conversely, bilirubin level was significantly associated with an increase in aPTT levels with respect to anti-Xa values. <h3>Conclusion</h3> A novel method developed to investigate the agreement between aPTT and anti-Xa in the peri-operative phase of TAH therapy showed comparatively low levels of anticoagulation (with respect to historical target aPTT range) were not associated with thromboembolic sequalae. Methodology developed for this study is generalisable to other forms of mechanical circulatory support.

Mechanical circulatory support in paediatric population.

Extra-corporeal membrane oxygenation is a life-saving modality to support the cardiac and/or pulmonary system as a form of life support in resuscitation, post-cardiotomy, as a bridge to cardiac transplantation and in respiratory failure. Its use in the paediatric and neonatal population has proven incredibly useful. However, extra-corporeal membrane oxygenation is also associated with a greater rate of mortality and complications, particularly in those with co-morbidities. As a result, interventions such as ventricular assist devices have been trialled in these patients. In this review, we provide a comprehensive analysis of the current literature on extra-corporeal membrane oxygenation for cardiac support in the paediatric and neonatal population. We evaluate its effectiveness in comparison to other forms of mechanical circulatory support and focus on areas for future development.

Unique Complications Associated With the Subclavian Intra-Aortic Balloon Pump

The intra-aortic balloon pump (IABP), which has been in use for more than 50 years, is one of the most common forms of mechanical circulatory support, with an estimated 200,000 inserted annually worldwide.1,2 Although commonly inserted through a femoral arteriotomy, the increasing usage of the IABP as a bridge-to-transplantation (BTT) in patients with advanced heart failure has led to the development of alternative sites, such as the subclavian (SCA) or axillary artery. This technique decreases the risk of infection and allows for ambulation, which limits deconditioning, all of which facilitate long-term use.

Fulminant Giant Cell Myocarditis Is Associated With Poor Outcomes

Background Giant cell myocarditis (GCM) is a rare autoimmune disorder that typically manifests with signs and symptoms of congestive heart failure, ventricular arrhythmias, or heart block. Diagnosis requires myocardial tissue to detect inflammatory infiltrates, with multinucleated giant cells and prominent myocyte necrosis. With immunosuppressive therapy, transplant-free 5-year survival rates range from approximately 40% to 60% across studies. However, the majority of published literature involves the entire spectrum of GCM, with minimal data on patients who present in cardiogenic shock. We hypothesized that patients who were critically-ill at presentation (fulminant myocarditis) would have a high likelihood of requiring advanced cardiac therapies, such as left ventricular assist device or heart transplantation (OHT). We report the demographics and outcomes of patients at a single-center who presented in fulminant giant cell myocarditis. Methods A natural language search for “giant cell myocarditis” was used to identify patients with a pathological diagnosis of GCM at the Vanderbilt University Medical Center between 1990 and 2020. Chart review of the results identified 7 patients who experienced cardiogenic shock during the index admission. Demographics, admission characteristics, and outcomes were analyzed. Results Major findings are shown in Figure 1. The median age at presentation was 53 years, with two of the seven patients having a history of left ventricular dysfunction. In all 7 patients, symptom-onset was within 30 days of presentation. The majority of patients experienced either ventricular arrhythmias or heart block. Hemodynamic assessment was consistent with cardiogenic shock, with elevated filling pressures and a median Fick cardiac index of 1.60 L/min/m2. All patients required support with at least one vasoactive agent. Five patients required an intra-aortic balloon pump, with two requiring escalation to extracorporeal membrane oxygenation (ECMO). Another patient required ECMO as the initial form of mechanical circulatory support. 30-day survival was 42.9%. Of the seven patients, three received steroids while another received a combination of steroids, thymoglobulin, and cyclosporine. The remaining three patients did not receive immunosuppressive therapy. Both the patients who survived for at least 1 year required OHT. Conclusions These findings suggest that GCM resulting in cardiogenic shock is rapidly progressive and highly lethal. Early mechanical circulatory support and urgent evaluation for advanced cardiac therapies may help improve outcomes. Large-scale studies are warranted to better understand this disease process.

Long-term mortality and costs following use of Impella® for mechanical circulatory support: a population-based cohort study.

The Impella® device is a form of mechanical circulatory support (MCS) used in critically ill adults with cardiogenic shock. We sought to evaluate short- and long-term outcomes following the use of Impella, including mortality, healthcare utilization, and costs. Population-based, retrospective cohort study of adult patients (≥ 16 yr) receiving Impella in Ontario, Canada (1 April 2012-31March 2019). We captured outcomes through linkage to health administrative databases. The primary outcome was mortality during hospitalization. Secondary outcomes included mortality at 30 days, 90 days, and one year following Impella insertion. We analyzed health system costs in Canadian dollars in the year following the date of the index admission, including the costs of inpatient admission. We included 162 patients. Mean (standard deviation) age was 59.2 (14.5) yr, and 73.5% of patients were male. Median [interquartile range (IQR)] time to Impella insertion from date of hospital admission was 2 [1-9] days. In-hospital mortality was 56.8%, and a significant proportion of patients were bridged to a ventricular assist device (67.9%). Mortality at one year was 61.7%. Among hospital survivors, only 38.6% were discharged home independently. Median [IQR] total cost in the year following admission among all patients was $88,397 [32,718-225,628], of which $66,529 [22,789-183,165] was attributed to inpatient care. In-hospital mortality among patients with cardiogenic shock receiving Impella is high, but with minimal increase at one year. While Impella patients accrued substantial costs, these largely reflected inpatient costs, and not costs incurred following hospital discharge.

Intraaortic Balloon Pump Counterpulsation, Part I: History, Technical Aspects, Physiologic Effects, Contraindications, Medical Applications/Outcomes.

Intraaortic balloon pump counterpulsation is the most common form of mechanical circulatory support used in patients with myocardial ischemia and cardiogenic shock. The physiologic principles of counterpulsation include diastolic augmentation of aortic pressure and systolic reduction of left ventricular afterload, resulting in hemodynamic benefits through increased coronary perfusion pressure and improved myocardial oxygen balance in patients with myocardial ischemia. Major trials have failed to conclusively demonstrate improvements in morbidity and mortality with counterpulsation therapy for patients with acute myocardial infarction (MI), cardiogenic shock, and/or severe coronary artery disease undergoing revascularization therapy, and the debate over its applications continues. Part I of this review focuses on the history of the development of counterpulsation, technical considerations, and complications associated with its use, its physiologic effects, and evidence for its use in myocardial ischemia and cardiogenic shock.

Simulation training on bedside veno-arterial extracorporeal membrane oxygenation decannulation.

Veno-arterial extracorporeal membrane oxygenation is a form of mechanical circulatory support for patients with refractory decompensated heart failure. Blood is drawn from a large vein and pumped back to a large artery, usually a femoral artery through large bore catheters. When the heart recovers, the extracorporeal membrane oxygenation support can be terminated and the catheters are decannulated. The bleeding at the venous side can be controlled by prolonged compression; however, the arteriotomy wound needs to be repaired. Conventionally, the arteriotomy wounds require open vascular repair in the operating theater. The novel application of percutaneous vascular closure devices, which have been commonly used in vascular operations and percutaneous structural heart interventions, could be applied for closure of arteriotomy wounds at the bedside after extracorporeal membrane oxygenation support. The post-close ProGlide (Abbott Vascular) technique was shown to be safe and could potentially save time and manpower. The wounds are much smaller as compared with the conventional open repair and potentially, the chance of wound infection can be reduced. However, the success of percutaneous bedside closure requires careful prior planning and technique training. Backup plans with vascular surgeons' standby are essential in case of failure of closure. Staffs in the extracorporeal membrane oxygenation centers need to be familiar with the preparation, the procedure as well as the device application technique for successful percutaneous closure. The long learning curve and the limited case load mean that such skills are best trained by simulation scenarios. This article described how this new technique and the team logistics can be trained by simulation.