Short-term Extracorporeal Membrane Oxygenation Research Articles

PULM14: Long-haul ECMO as Bridge to Transplant in COVID-19 ARDS

Background: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LT) is an established treatment modality for refractory acute respiratory distress syndrome (ARDS). Per the Scientific Registry of Transplant Recipients (SRTR) database, 215 patients supported on ECMO due to the Coronavirus disease of 2019 (COVID-19) related ARDS underwent LT between August 2020 and June 2022. The COVID-19 pandemic limited donor availability and increased duration of ECMO support in ECMO-dependent patients listed for LT. Outcomes of long-term ECMO as bridge to transplant (BTT) in this population remain unclear, and no cases of VV ECMO greater than 200 days has been documented in the literature. Methods: A single-center review was conducted to identify patients cannulated for VV-ECMO to treat COVID-19 associated ARDS between January 1, 2021 and January 1, 2022. Patients were selected who were supported by VV-ECMO for ARDS secondary to COVID-19 for greater than 200 days before receiving a lung transplant. Detailed analysis was performed for the outcomes and characteristics of all patients who received a lung transplant for post-COVID-19 ARDS after >200 days of VV-ECMO support. Results: Three patients were identified as long-term ECMO as BTT recipients (>200 days) for COVID-19-associated ARDS. Average age was 38 years (22,52), BMI 32.9 (31.6,34) and no patients had any known relevant respiratory medical history. One patient had a history of daily e-cigarette use. All patients were unvaccinated at the time of first positive COVID-19 test. All were successfully bridged to bilateral lung transplant (BLT) off of VV-ECMO. None required VV-ECMO post-operatively. One patient required VA-ECMO post-operatively for elevated pulmonary arterial pressures related to incidentally discovered septal defects. Average ECMO duration was 278 days (250, 324). Two patients were cannulated as bridge to recovery, and one as bridge to decision. Patients remained ambulant on ECMO support until they were able to undergo the transplant procedure. Cannulation strategies included double lumen right internal jugular (RIJ), RIJ to right femoral vein, and bifemoral venous cannulation. Complications on ECMO included sepsis, hemorrhage, stroke, reconfiguration, and atrial fibrillation. Two were discharged to home and one to inpatient rehabilitation. Average length of stay after transplant was 27 days (16,37). All 3 patients have continued to do well. Conclusion: We present three patients with the longest documented VV-ECMO support for COVID-19 ARDS a bridge to lung transplant. Our findings suggest long-term VV-ECMO support is a feasible bridge to LT for patients with COVID-19-related ARDS when used in the long-term (>200 days). The duration of ECMO support remains associated with known ECMO-related complications. Post-transplant survival to-date suggests that survival in long-term ECMO support as a BTT may be comparable to short-term ECMO in patients with COVID-19-related ARDS.

Extracorporeal membrane oxygenation seems to induce impairment of primary hemostasis pathology as measured by a Multiplate analyzer: An observational retrospective study.

Extracorporeal membrane oxygenation (ECMO) support is often associated with bleeding complications caused by secondary or primary hemostasis pathology. However, there are limited data investigating primary hemostasis using Multiplate aggregometry with specific diagnostics tests for vWF (von Willebrand factor) deficiency. The aim of this study was to find out whether short-term ECMO produces the pathology of primary hemostasis that is detected by Multiplate aggregometry and to investigate the pathology of vWF. In this study, blood samples of 20 patients undergoing lung transplantations with short-term perioperative ECMO support were analyzed. The multimeric structure, the levels of von Willebrand factor antigen (vWF), ristocetin cofactor (RCo), collagen-binding protein (CB), and the results of multiple electrode aggregometry RISTO (ristocetin), ADP (adenosine diphosphate), ASPI (Aspirin®; arachidonic acid), and TRAP (thrombin receptor activating peptide) tests were compared to the samples obtained before and after ECMO support. The Multiplate ADP and RISTO tests showed the presence of significant pathology in primary hemostasis after surgery (p<0.05), suggesting the presence of acquired platelet dysfunction. Although the RISTO tests suggest the presence of acquired vWF deficiency, laboratory tests for vWF antigen and RCo and CB tests showed an increase in this case. The multimeric structure of vWF did not show clinically significant deterioration. Multiple aggregometry ADP, ASPI, and TRAP tests seem to be able to detect primary hemostasis pathology (platelets aggregation and adhesion pathology) that is present during short-term perioperative ECMO support in lung transplantation procedures. Interestingly, RISTO tests seem to be more suitable for the diagnosis of platelet dysfunction than the diagnosis of acquired vWF deficiency in this situation.

TELE-ECMO FOR A YOUNG, ACTIVE DUTY SERVICEMEMBER IN A DOMESTIC COVID-19 HOTSPOT

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Through the Joint Tele-Critical Care Network (JTCCN), the U.S. military has demonstrated that tele-critical care (TCC) services can facilitate the safe delivery of critical care beyond the consulting provider's level of training. While TCC has been described in a variety of scenarios, virtual health support of adult extracorporeal membrane oxygenation (ECMO) management has not been previously reported. We present a case of a young, active duty servicemember with COVID-19 pneumonia complicated by acute hypoxemic respiratory failure refractory to conventional therapy who was cannulated for veno-venous ECMO and successfully managed for 72 hours with TCC support. CASE PRESENTATION: A 39 year-old male Active Duty Service Member (ADSM) presented to Naval Medical Center San Diego (NMCSD) with hypoxemic respiratory failure five days after a positive SARS-CoV-2 PCR test. He was given supportive oxygen therapy, Remdesivir and dexamethasone. On hospital day nine, he was intubated for refractory hypoxemia and the ratio of arterial pO2 to fraction of inspired oxygen (P/F ratio) one hour later was 74. Neuromuscular blockade and prone positioning were initiated. Three days later, the P/F ratio remained less than 100. A request to transfer the patient to a local partner facility for ECMO was declined due to lack of bed availability.The San Antonio Military Medical Center (SAMMC) ECMO Team was consulted via TCC and the patient was placed on veno-venous ECMO, as personnel at NMCSD had previously undergone cannulation training. The NMCSD critical care team had round-the-clock secure video teleconferencing connection to the perfusionists and physician ECMO specialists at SAMMC during this time. After 72 hours of tele-ECMO management without complications, a U.S. Air Force Critical Care Air Transport Team safely transferred the patient 1,276 miles by fixed-wing aircraft to SAMMC for ongoing care. DISCUSSION: As the only certified ECMO center in the Department of Defense and one of the few centers in the world with global air transport capability, SAMMC has partnered with NMCSD to provide short-term ECMO care with TCC support. Previously, this capability had not been demonstrated over a period longer than a few hours. Because this patient's clinical decompensation occurred during the peak of the COVID-19 surge in Southern California, rapid transfer to a local ECMO center was not possible. In this case, JTCCN enabled the provision of lifesaving advanced cardiopulmonary support to an ADSM until aeromedical evacuation could be arranged. CONCLUSIONS: This case serves as proof-of-concept for a hub and spoke model of tele-ECMO support to global military medical facilities, demonstrating the potential to bring sophisticated lifesaving technology to medically-austere environments anywhere in the world. REFERENCE #1: Davis K, Perry-Moseanko A, Tadlock MD, Henry N, Pamplin J. Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations. Mil Med. 2017 May;182(5):e1702-e1707. doi: 10.7205/MILMED-D-16-00277. PMID: 29087914. REFERENCE #2: Read MD, Nam JJ, Biscotti M, Piper LC, Thomas SB, Sams VG, Elliott BS, Negaard KA, Lantry JH, DellaVolpe JD, Batchinsky A, Cannon JW, Mason PE. Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team. Mil Med. 2020 Dec 30;185(11-12):e2055-e2060. doi: 10.1093/milmed/usaa215. PMID: 32885813. REFERENCE #3: Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021 Feb 26. doi: 10.1097/MAT.0000000000001422. Epub ahead of print. PMID: 33657573. DISCLOSURES: No relevant relationships by John Hunninghake, source=Web Response No relevant relationships by Phillip Mason, source=Web Res onse No relevant relationships by Jeremy Pamplin, source=Web Response No relevant relationships by Nick Rohrhoff, source=Web Response No relevant relationships by Melissa Rosas, source=Web Response No relevant relationships by Jesse Sherratt, source=Web Response No relevant relationships by Robert Walter, source=Web Response

The intersection of bronchoscopy and extracorporeal membrane oxygenation.

Central airway obstruction (CAO), which results from malignant, benign or iatrogenic etiologies, causes significant morbidity and mortality and can be seen in both the pediatric and adult patient population. Patients frequently present to the hospital with dyspnea, stridor, and respiratory distress, indicating impending respiratory failure. Heliox is used to help alleviate symptoms while procedural planning takes place. A multidisciplinary approach to airway management is often needed. Interventional pulmonologists treat CAO with rigid of flexible bronchoscopy in order to deliver therapeutic interventions under general anesthesia. In severe CAO where there is concern for total loss of the airway creating a life-threatening situation for the patient during procedural intervention, short term extracorporeal membrane oxygenation or ECMO has been successfully reported in the literature to provide ventilation and oxygenation support throughout the procedure. Venoarterial ECMO can be used to augment cardiac output in cases of central tumors with cardiac involvement. ECMO can also be used for the removal of tracheal stents when there is a concern that ventilation will be interrupted for a prolonged period of time. ECMO has also been reported as a salvage measure for patients with life threatening hemoptysis until more definitive interventions can be performed. Short term ECMO cannulation can be used with limited associated morbidity and a heparin-free approach can be pursued when there is a concern for bleeding. We will briefly review the anesthetic considerations in CAO as well as review cases of CAO where ECMO was employed to safely alleviate the airway compromise.

Normothermic extracorporeal membrane oxygenation support: Improving the function of intestinal grafts obtained from cardiac death donors.

Extracorporeal membrane oxygenation (ECMO) could ameliorate the energy status and viability of bowel grafts from cardiac death donors. However, the function of these grafts after transplantation is not clear. The purpose of the study was to evaluate the early function of intestinal grafts after transplantation from expected cardiac death donors supported with normothermic extracorporeal support using a porcine allogeneic orthotopic segmental small bowel transplantation model. Eighteen domestic crossbred donor pigs were assigned to living donation (LD), donation after cardiac death (DCD), and ECMO groups. In the LD group, small bowels were harvested and preserved immediately in cold storage. In the other two groups, the donor pigs received conventional rapid recovery treatment or 1-hour normothermic extracorporeal support after 10-minutes expected cardiac arrest. Subsequently, the small bowels were removed and preserved in cold storage. After 5-6hours of preservation, small bowel grafts were transplanted into the recipient pigs that underwent enterectomy. The pathology and electron microscopy results, cell apoptosis rate, tight junction protein expression level in the intestinal mucosa, and plasma endotoxin level were evaluated after transplantation. All grafts functioned on the basis of the maltose absorption test results at day 7 after transplantation. There were no significant differences in the morphological changes in the intestinal mucosa among the three groups at day 7 after transplantation. The cell apoptosis rate and plasma endotoxin level in the ECMO group did not differ significantly than those in the LD group, but were evidently lower than those in the DCD group (P<.001). The intestinal absorptive function improved significantly in the ECMO group in contrast with that in the DCD group (P<.001). Short-term ECMO intervention can alleviate ischemia-reperfusion injuries in intestinal grafts and improve intestinal absorptive function in the early stage after transplantation. Reducing caspase-3 protein expression and cell apoptosis in the intestinal mucosa may be one of the protective mechanisms of ECMO intervention.

Short-term venoarterial extracorporeal membrane oxygenation for massive endobronchial hemorrhage after pulmonary endarterectomy

ObjectivesPulmonary endarterectomy (PEA) is the only curative treatment option for patients with chronic thromboembolic pulmonary hypertension. Massive endobronchial bleeding that precludes weaning from cardiopulmonary bypass is an often-fatal complication of PEA. The aim of this study was to determine whether short-term extracorporeal membrane oxygenation (ECMO) is a safe and feasible procedure in patients with severe endobronchial bleeding. MethodsFrom January 2014 to December 2016, 396 patients (mean age 60 ± 18 years, 54.5% male) underwent PEA in our department. Patients with severe endobronchial hemorrhage at the time of weaning from cardiopulmonary bypass (CPB) were switched to a heparin-coated venoarterial ECMO circuit. After full-dose protamine administration to restore normal coagulation, weaning from ECMO was attempted in the operating room. ResultsIn-hospital mortality was 2.3% (9/396 patients). Eight patients (2.0%) developed severe endobronchial bleeding classified as diffuse (n = 6) or localized (n = 2) by bronchoscopy. After reinstitution of CPB and subsequent switch to ECMO, the mean duration of ECMO support was 49 ± 13 minutes, and all 8 patients were weaned successfully from ECMO in the operating theater without further signs of endobronchial bleeding. One patient needed venovenous ECMO support for poor oxygenation 6 hours after surgery. Seven patients were discharged after a prolonged postoperative stay of 17.6 ± 4.1 days. One patient died. This new concept significantly reduced mortality compared with previous (2009-2013) ECMO support (P = .0406). ConclusionsFor patients with massive endobronchial bleeding after PEA, the intraoperative switch from CPB to venoarterial ECMO support with full-dose protamine administration is a new and potentially life-saving treatment concept.

Ovine platelet function is unaffected by extracorporeal membrane oxygenation within the first 24 h.

This study investigated platelet dysfunction during short-term extracorporeal membrane oxygenation (ECMO) and secondarily to determine if hyperoxaemia contributes to this dysfunction. Healthy sheep were anaesthetized and maintained on ECMO for either 2 or 24 h, with or without induction of smoke inhalation acute lung injury. A specialized animal-operating theatre was used to conduct the experimentation. Forty-three healthy female sheep were randomized into either a test or a control group. Following anaesthesia, test groups received ECMO ± smoke inhalation acute lung injury (SALI), whereas control groups were maintained with ventilation only ± SALI. Physiological, biochemical and coagulation data were obtained throughout via continuous monitoring and blood sampling. Platelet function was quantified through whole blood impedance aggregometry using Multiplate. Ovine platelet activity induced by adenosine diphosphate (ADP) and collagen was unaffected during the first 24 h of ECMO. However, progressive divergence of ADP-induced platelet activity was noted at cessation of the experiment. PaO2 was inversely related to ADP-dependent platelet activity in the ECMO groups--a relationship not identified in the control groups. ADP and collagen-dependent platelet activity are not significantly affected within the first 24 h of ECMO in sheep. However, dysfunction in ADP-dependent platelet activity may have continued to develop if observed beyond 24 h. Hyperoxaemia during ECMO does appear to affect how platelets react to ADP and may contribute to this developing dysfunction. Long-term animal models and investigation in clinical animals are warranted to fully investigate platelet function during ECMO.

Long-Term Venovenous Extracorporeal Membrane Oxygenation Support for Acute Respiratory Distress Syndrome

Given substantial advances in venovenous extracorporeal membrane oxygenation (ECMO) technology, long-term support is increasingly feasible. Although the benefits of short-term ECMO as a bridge to recovery in acute respiratory distress syndrome (ARDS) are well described, the utility and outcomes of long-term support remain unclear. Patients requiring ECMO for ARDS between January 2009 and November 2012 were retrospectively reviewed and analyzed separately for those requiring ECMO support for less than 3 weeks or for 3 weeks or longer. Demographic factors, ECMO variables, and outcomes were assessed. Fifty-five patients with ARDS received ECMO during the study period, with 11 patients requiring long-term ECMO support and a median duration of 36 (interquartile range: 24 to 68) days. Recovery was the initial goal in all patients. Pre-ECMO mechanical ventilatory support, indices of disease severity, and the ECMO cannulation strategy were similar between the two groups. Eight (73%) patients receiving long-term support were bridged to recovery, and 1 patient was bridged to transplantation after a refractory course. Eight (73%) patients receiving long-term support and 25 (57%) patients receiving short-term support survived to 30 days and hospital discharge. Previously, long-term ECMO support was thought to be associated with unfavorable outcomes. This study, however, may provide support for the efficacy of ECMO support even for 3 weeks or more as a bridge to recovery or transplantation.

Abstract 15650: Nutritional Support With Medium Chain Fatty Acids During Extracorporeal Membrane Oxygenation in Infant Swine Model

Background: Extracorporeal membrane oxygenation (ECMO) is the most frequently used mechanical circulatory support in children with cardiopulmonary failure. Nutritional energy support as well as inotropic support is important to recover cardiac function during ECMO. Fatty acids (FAs) are major myocardial energy source for citric acid cycle (CAC). Medium-chain FAs (MCFAs) are easily uptaken into cell and mitochondria without membrane transporters. Our previous animal study suggested that MCFAs can potentially use for myocardial energy metabolism as the best accessible substrates during ECMO. Even-numbered MCFAs enter into CAC via acetyl-CoA, while odd-numbered MCFAs are anaplerotic for the CAC as propionyl-CoA in addition to acetyl-CoA. This study assessed whether odd- or even-numbered MCFAs product efficient energy during a short-term ECMO. Methods: Fifteen male Yorkshire pigs (26-45 days old) with 8-hour ECMO were received either normal saline, heptanoate (odd-numbered MCFA) or octanoate (even-numbered MCFA) at 2.3 μmol/kg body wt/min as MCFAs systemically during ECMO (n = 5 per group). The 13-Carbon ( 13 C) labeled substrates ([2- 13 C]lactate, [5,6,7- 13 C 3 ]heptanoate and [U- 13 C 6 ]leucine) as metabolic markers were infused into coronary artery for the final hour before left ventricular tissue extraction. Extracted left ventricular tissues were analyzed for the 13 C-labeled and absolute concentrations of metabolites by nuclear magnetic resonance and gas chromatography-mass spectrometry. Results: There were no adverse events in any groups during experiments. Octanoate produced markedly high citrate concentration, indicating the conjugation of CAC, and led to high [ATP]/[ADP] ratio compared with other groups (6.2 ± 0.6, 6.0 ± 0.6 and 7.8 ± 0.5 in normal saline, heptanoate and octanoate, P &lt; 0.05). Octanoate strongly increased the CAC metabolism through anaplerotic pathway from propionyl-CoA, but not heptanoate. Lactate oxidation and protein synthesis ratio from leucine were not different among 3 groups. Conclusions: Even-numbered MCFAs was superior energy source for CAC than odd-numbered MCFAs in normal heart supported with ECMO. These results support that nutritional therapy with even-numbered MCFAs facilitates weaning from ECMO.

Ethical Dilemma

The use of extracorporeal membrane oxygenation (ECMO) in terminally ill pediatric patients who are not candidates for long-term mechanical circulatory support or heart transplantation requires careful deliberation. We present the case of a 16-year-old female with a relapse of acute lymphoid leukemia and acute-on-chronic cardiomyopathy who received short-term ECMO therapy. In addition, we highlight several ethical considerations that were crucial to this patient's family-centered care and demonstrate that this therapy can be accomplished in a manner that respects patient autonomy and family wishes.

Outcomes of Long-Term Veno-Venous Extracorporeal Membrane Oxygenation Support for Acute Respiratory Distress Syndrome

Purpose Given substantial advances in veno-venous extracorporeal membrane oxygenation (ECMO) technology, long-term support is increasingly feasible. Although the benefits of short-term ECMO as a bridge to recovery in acute respiratory distress syndrome (ARDS) are well described in the literature, the outcomes of patients requiring long-term support remain unclear. Methods and Materials Patients requiring ECMO for ARDS between January 2009 and November 2012 were retrospectively reviewed and analyzed separately for those requiring short-term and long-term ECMO support (≥3 weeks). Demographics, ECMO variables and outcomes of patient bridged to recovery or transplantation were assessed. Results 57 patients with ARDS were placed on ECMO during that time period with 11 patients requiring long-term ECMO support (59±51 days). Recovery was the goal in all patients. In the long-term support group, pre-ECMO mechanical ventilation was conventional PC or PRVC (N=4), APRV (N=5), or HFO (N=2). The mean pre-ECMO FiO2 was 0.93±0.13 with mean pH, PaO2, and PaCO2 of 7.3±0.1, 69±26 mmHg, 63±21 mmHg, respectively. Pre-ECMO Murray Scores were 3.7±0.4 and 3.82±0.29 (p=NS) in the long-term and short-term groups, respectively. 8 (73%) long-term support patients were successfully bridged to recovery and 1 patient was bridged to transplantation after a refractory course. 25 (52%) short-term support patients and 8 (73%) long-term support patients survived to 30-days or hospital discharge. In the long-term support group, 4 of the 8 surviving patients had mid-term follow-up available; with 100% surviving, returned to home, and with normal functional status at 1 year. Conclusions Previously, long-term ECMO support has not been thought to be associated with favorable outcomes. This study, however, may provide support for the efficacy of ECMO for patients even requiring support greater than 3 weeks as a bridge to recovery or transplantation.

Invited Commentary

Invited Commentary

20-Year Experience of Prolonged Extracorporeal Membrane Oxygenation in Critically Ill Children With Cardiac or Pulmonary Failure

Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for life-threatening respiratory or circulatory failure. Although outcomes are favorable with short-term ECMO therapy, data on the outcomes of prolonged ECMO therapy in children are very limited. This study aimed to study morbidity and mortality associated with prolonged ECMO therapy (≥28 days) in children with refractory cardiac or pulmonary failure. We conducted a retrospective review of all children≤18 years supported with ECMO for ≥28 days between January 1991 and September 2011 at the Arkansas Children's Hospital. The data collected in our study included patient demographic information; diagnosis; indication for ECMO; ECMO support details; medical and surgical history; laboratory, microbiologic, and radiographic data; information on organ dysfunction; complications; and patient outcomes. The outcome variables evaluated in this report included survival to ECMO decannulation, survival to hospital discharge, and current survival with emphasis on neurologic, renal, pulmonary, and other end organ function. During the study period, 984 events in 951 patients were supported with ECMO with a 30-day survival of 666 events (68%). Only 22 ECMO runs were ≥28 days and were eligible for inclusion in this report. The longest ECMO run in our series was 1,206 hours (50 days). The average length of ECMO run in this cohort was 855±133 hours, with a mean intensive care unit length of stay of 56±27 days. Ten patients (45%) were successfully decannulated from ECMO. Six patients (27%) were alive 30 days after decannulation, and only 4 patients (19%) survived to hospital discharge. Of the 4 survivors, only 3 patients (14%) are living to date. Of the 3 living children, 2 have significant neurologic issues with brain atrophy and developmental delay, and 1 is awaiting renal transplant; all 3 survivors have chronic lung disease. This case series highlights that the prolonged use of ECMO in children with refractory cardiac failure, respiratory failure, or both is associated with low survival. Furthermore, it suggests that the survivors of prolonged ECMO runs have significant long-term sequelae.

Successful extracorporeal membrane oxygenation treatment for pheochromocytoma-induced acute cardiac failure

The aim of this study is to report the case of a catecholamine-induced cardiogenic shock bridged to curative adrenalectomy using extracorporeal membrane oxygenation (ECMO) and medical management. A 37-year-old woman presented an acute cardiogenic shock due to a left-sided pheochromocytoma. Echocardiography revealed a severe global hypokinesia with a left ventricular ejection fraction of 15%. Despite maximal ionotropic support, adequate perfusion could not be achieved; and ECMO was used to bridge the patient during medical management with calcium-channel blockers. The left ventricular ejection fraction improved to 65%, and ECMO was discontinued after 11 days. An open left adrenalectomy was performed 10 days after ECMO. At 1-year follow-up, the patient is in good health with normal cardiac function. Pheochromocytomas can present with dramatic cardiovascular collapse. With timely diagnosis and medical therapy, followed by surgical resection, the cardiovascular effects can be reversed; and the condition, cured. Young patients with catecholamine-induced cardiac failure refractory to medical therapy are ideal candidates for short-term ECMO support, as the underlying cause is imminently reversible.

Extracorporeal Membrane Oxygenation (Ecmo): Extended Indications for Artificial Support of Both Heart and Lungs

Extracorporeal membrane oxygenation (ECMO) was used to achieve temporary artificial support in cardiac and pulmonary function in 22 patients from 1987 to September 1990. Standard indications were postcardiotomy cardiogenic shock (n = 4), neonatal (n = 1) and adult respiratory distress syndrome (n = 4). ECMO was also used for extended indications, such as graft failure following heart (n = 11) or lung transplantation (n = 2). In six of these cases ECMO was instituted as a bridge device to subsequent retransplantation of either the heart (n = 4) or one lung (n = 2). One out of nine patients supported by ECMO for standard indications, and two out of 13 patients supported for extended indications are long-term survivors. This series illustrates the results with ECMO in emergency situations, in patients under immunosuppressive protocols, or in patients with advanced lung failure requiring almost complete artificial gas exchange. In such complex situations, ECMO does provide stabilization until additional therapeutic measures are in effect. ECMO cannot be recommended for postoperative cardiogenic shock but short-term ECMO support is an accepted method in most cases with graft failure or pulmonary failure or other origin.