CathMasters by CardioNerds

CathMasters Drs. Nazli Okumus and Daniel Ambinder, along with expert faculty Drs. Ann Gage and Marwan Jumean, tackle the management of limb ischemia — one of the most feared complications of peripheral VA-ECMO (veno-arterial extracorporeal membrane oxygenation) and large-bore mechanical circulatory support (MCS). Through the case of a 50-year-old woman with ischemic cardiomyopathy on VA-ECMO and Impella CP who develops right leg ischemia, the team walks through bedside assessment of the ischemic limb, equipment and technique for placing a distal perfusion catheter (DPC) on an existing ECMO circuit, strategies to mitigate limb ischemia with Impella, assessment of vascular patency during large-bore access removal, and the recognition and management of compartment syndrome. 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 Limb ischemia on VA-ECMO is a clinical diagnosis made at the bedside. Compare the cannulated leg to the non-cannulated leg: assess color (pallor, mottling), temperature, capillary refill, and Doppler signals (dorsalis pedis and posterior tibial). Near-infrared spectroscopy (NIRS) provides continuous, objective monitoring — an absolute rSO2 <40%, a >20% drop from baseline, or a>15–20% difference between legs should prompt urgent evaluation. The distal perfusion catheter (DPC) should be the standard of care for all patients on femoral VA-ECMO. Prophylactic DPC reduces limb ischemia by ~60% (OR 0.31–0.41). When placing a DPC on a patient already on ECMO, use ultrasound-guided antegrade access into the superficial femoral artery (SFA) — the stick is more challenging with a large arterial cannula already in place, so patience and meticulous ultrasound technique are critical. For Impella CP, the 14F peel-away introducer sheath can be removed (“peeled away”), leaving only the smaller 9F repositioning sheath around the catheter. This simple maneuver may be sufficient to restore distal limb perfusion without the need for a separate DPC. After removing any large-bore access (TAVR sheath, Impella, ECMO cannula), consider performing completion angiography — ideally via radial or contralateral femoral access — to confirm vessel patency and rule out dissection, thrombosis, or stenosis before leaving the lab. Compartment syndrome on ECMO is paradoxically most dangerous after reperfusion, not during ischemia. When a DPC is placed in an ischemic limb, reperfusion causes cellular edema within fascial compartments. If compartment pressures exceed 20 mmHg (or are within 30 mmHg of diastolic blood pressure), emergency fasciotomy is required. Elevated CPK and lactate are late and concerning findings — do not wait for them. Notes 1. Assessment of an Ischemic Limb Limb ischemia occurs in approximately 10–20% of patients on peripheral VA-ECMO, historically 16.9% with fasciotomy needed in 10.3% and amputation in 4.7%. Contemporary data from high-volume centers using prophylactic DPC, smaller arterial cannulas, and ultrasound-guided access report limb ischemia rates as low as 3.5%. The mechanism is multifactorial: the large arterial cannula (15–20F) partially or completely occludes the common femoral artery, reducing antegrade flow to the ipsilateral leg. Contributing factors include peripheral arterial disease (PAD), hemodynamic instability/low cardiac output, vasoconstriction from vasopressors, and thromboembolism. Bedside assessment (compare cannulated vs. non-cannulated leg): Inspection: Pallor, mottling, cyanosis, or dusky discoloration. Late findings include blistering and gangrene. Palpation: Temperature differential (cool vs. warm), capillary refill time (>3 seconds is concerning), and palpation of pedal pulses. Doppler assessment: Check dorsalis pedis (DP) and posterior tibial (PT) artery signals. Absent or monophasic signals on the cannulated side with normal signals contralaterally are highly concerning. Hourly Doppler checks should be standard nursing protocol. NIRS monitoring: Near-infrared spectroscopy placed on the calves of both legs provides continuous, real-time tissue oxygen saturation (rSO2). An absolute rSO2 <40%, a drop >20% from baseline, or a difference >15–20% between legs should trigger urgent evaluation. Studies demonstrate that NIRS-guided DPC placement reduces limb ischemia requiring surgical intervention from 8.5% to 2.6% and eliminates the need for fasciotomy in monitored cohorts. Laboratory markers: Elevated serum creatine phosphokinase (CPK) and lactate levels are late and very concerning findings, indicating that muscle necrosis has already begun. These should not be relied upon for early detection. Risk factors for limb ischemia: PAD (OR 2.19), female sex, smaller vessel caliber, larger arterial cannula size, diabetes, and prolonged ECMO duration. 2. Equipment for Adding a DPC to a Patient on ECMO Vascular ultrasound (linear probe) Micropuncture access kit (21G needle, 0.018″ wire, 4–5F micropuncture sheath) 0.035″ guidewire for exchange Antegrade sheath: 5–8F braided sheath (braided sheaths resist kinking in the antegrade orientation). A 6F or 7F sheath is most commonly used. Y-connector and arterial tubing to connect the DPC sheath side-arm to the arterial limb of the ECMO circuit Fluoroscopy (if available) to confirm wire position in the SFA and rule out inadvertent entry into the profunda femoris Sterile prep and drape for the ipsilateral groin/thigh Sheath size selection: The DPC sheath should be large enough to provide adequate flow but small enough to avoid further vascular compromise. A 6–7F sheath is standard. The donor vessel (ECMO arterial limb) should ideally be a larger French size than the recipient (DPC sheath) to promote flow via a high-to-low pressure gradient. 3. Procedure for Adding a DPC to a Patient Already on ECMO This is one of the more technically challenging sticks in interventional cardiology because the large arterial cannula already occupies the CFA, thereby limiting space and altering anatomy. Step 1 — Position and prep: The patient is supine. Sterile prep of the ipsilateral groin and thigh. Identify the SFA distal to the arterial cannula insertion site using ultrasound. Step 2 — Ultrasound-guided antegrade CFA-SFA access: Using a linear ultrasound probe, identify the SFA below the femoral bifurcation, distal to the ECMO arterial cannula. Perform an antegrade stick with a micropuncture needle. The key challenge is that the large cannula may compress or displace the SFA, and flow in the SFA may be diminished, making the vessel harder to visualize and access. Step 3 — Wire and sheath placement: Advance the micropuncture wire and confirm position with fluoroscopy, if available (ensure the wire is in the SFA, not the profunda femoris). Exchange for a 0.035″ wire and place a 6–7F braided sheath in the antegrade direction. Step 4 — Connect to circuit: Connect the side-arm of the DPC sheath to the arterial limb of the ECMO circuit using a Y-connector and arterial tubing. This diverts a portion of oxygenated, pressurized blood from the ECMO circuit into the distal leg. Step 5 — Confirm perfusion: Reassess distal pulses by Doppler, check NIRS values, and assess clinical improvement (color, temperature, capillary refill). Improvement should be seen within minutes. Alternative approaches if antegrade SFA access is not feasible: Retrograde posterior tibial artery access with a 5–6F sheath Contralateral femoral-to-ipsilateral SFA internal bypass (up-and-over technique): Retrograde access of the contralateral CFA with a 7F sheath, advance a 4–5F sheath up and over the aortic bifurcation into the ipsilateral SFA or profunda Surgical cutdown with side-arm graft sewn onto the femoral artery 4. Ischemia Avoidance with Impella Limb ischemia with Impella CP occurs in up to 12.5% of cases, primarily due to the occlusive 14F introducer sheath in the CFA. Peel-away sheath technique: The Impella CP is inserted through a 14F peel-away introducer sheath. Once the device is positioned and secured, the outer 14F sheath can be “peeled away” (split and removed), leaving only the 9F repositioning sheath around the Impella catheter. This reduces the effective sheath size from 14F to 9F, which may be sufficient to restore adequate distal perfusion. DPC configuration for Impella: If peeling away the sheath is insufficient, a DPC can be placed using the same antegrade SFA technique described above. The donor vessel options include: Ipsilateral CFA: External bypass from the large-bore sheath side-port to the DPC sheath side-port using a male-to-male connector and arterial tubing Contralateral femoral artery: External bypass to the antegrade ipsilateral SFA sheath Contralateral femoral internal bypass: Up-and-over technique General principles: Minimize arterial cannula/sheath size when possible, use ultrasound-guided access to ensure a clean CFA stick, and continuously monitor distal perfusion with NIRS and perform hourly Doppler checks. 5. Assessing Vascular Patency During/After Large-Bore Access Removal Vascular complications after large-bore access removal (TAVR, Impella, VA-ECMO decannulation) are common and include thrombosis, dissection, stenosis, pseudoaneurysm, and distal embolization. Strategies for assessment: Pre-removal baseline: Document pedal pulses (Doppler DP and PT signals) and NIRS values on the ipsilateral leg before decannulation. Know what the baseline was so post-removal changes can be detected. Completion angiography: After achieving hemostasis, perform angiography of the access vessel — ideally via radial access or contralateral femoral access. This confirms vessel patency, rules out dissection/thrombosis/stenosis, and identifies any residual thrombus. This is the single most important step. Post-closure Doppler assessment: Immediately after closure, reassess pedal pulses. Loss of previously present signals warrants urgent angiography and potential intervention. Protamine administration: After hemostasis is achieved, protamine can be used to reverse residual heparin effect and reduce oozing from the access site. Dry-field closure technique: Via radial or contralateral femoral access, a peripheral balloon sized 1:1 with the ipsilateral external iliac artery can be inflated at 2–4 atm to achieve temporary hemostasis during deployment of suture-based closure devices, providing a controlled, bloodless field. Post-procedure surveillance: Vascular duplex ultrasound within 24–48 hours to screen for pseudoaneurysm, AV fistula, or thrombosis may be considered. Late vascular complications occur in ~8% of survivors and may present weeks to months after discharge. 6. Compartment Syndrome and Fasciotomy Compartment syndrome is a surgical emergency that occurs when pressure within a closed fascial compartment rises to a level that compromises tissue perfusion, leading to muscle necrosis and potentially limb loss. Paradox of reperfusion: Compartment syndrome is rarely seen in profoundly ischemic limbs before reperfusion. It is most commonly triggered after reperfusion — when a DPC is placed in an ischemic limb, or when ECMO is initiated, and flow is restored. Reperfusion causes cellular edema, capillary leak, and swelling within the rigid fascial compartments of the lower leg. Incidence: ECMO-associated compartment syndrome occurs in approximately 2.5% of all ECMO patients (598/24,047 in a national database study). Lower extremity compartment syndrome accounts for 85% of cases. Mortality in patients who develop ECMO-associated compartment syndrome is 58–65%. Clinical findings: The limb becomes swollen and the skin taut. Pain out of proportion to exam (though often difficult to assess in sedated/intubated patients), pain with passive stretch of the compartment muscles, and a tense/woody feel to the compartment are classic findings. Diagnosis: Clinical suspicion is paramount — do not wait for laboratory confirmation. Compartment pressure measurement: A pressure >20 mmHg warrants fasciotomy per the JACC Expert Panel. The ACC/AHA PAD guideline uses a delta pressure threshold (compartment pressure within 30 mmHg of diastolic blood pressure) as an alternative criterion. Laboratory: Elevated CPK (often markedly elevated, >10,000 U/L) and rising lactate are late findings indicating muscle necrosis has already occurred. Myoglobinuria (dark urine) may be present. Management: Emergency four-compartment fasciotomy of the lower leg (anterior, lateral, superficial posterior, deep posterior) by a surgeon (vascular, orthopedic, or trauma surgery). Time to fasciotomy is critical — delays correlate with worse muscular findings and higher rates of amputation. Prophylactic fasciotomy should be considered at the time of reperfusion in patients with prolonged ischemia (>4–6 hours) or severe tissue ischemia (Rutherford IIa/IIb). Systemic consequences of reperfusion/rhabdomyolysis: Hyperkalemia, metabolic acidosis, acute kidney injury from myoglobin nephrotoxicity. Aggressive IV hydration and monitoring of electrolytes and renal function are essential. If the limb is unsalvageable (extensive necrosis, gangrene), amputation may be necessary. Historically, 4.7% of VA-ECMO patients required amputation; contemporary rates at high-volume centers are <1%. References ★ Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for adults: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019;73(6):698-716. doi:10.1016/j.jacc.2018.11.038 ★ Damluji AA, Tehrani B, Sinha SS, et al. Position statement on vascular access safety for percutaneous devices in AMI complicated by cardiogenic shock. JACC Cardiovasc Interv. 2022;15(20):2049-2071. doi:10.1016/j.jcin.2022.08.040 ★ Bonicolini E, Martucci G, Simons J, et al. Limb ischemia in peripheral veno-arterial extracorporeal membrane oxygenation: a narrative review of incidence, prevention, monitoring, and treatment. Crit Care. 2019;23(1):266. doi:10.1186/s13054-019-2541-3 ★ Marbach JA, Faugno AJ, Pacifici S, et al. Strategies to reduce limb ischemia in peripheral venoarterial extracorporeal membrane oxygenation: a systematic review and meta-analysis. Int J Cardiol. 2022;361:77-84. doi:10.1016/j.ijcard.2022.04.084 ★ Lamb KM, DiMuzio PJ, Johnson A, et al. Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation. J Vasc Surg. 2017;65(4):1074-1079. doi:10.1016/j.jvs.2016.10.071 ★ Vinogradsky A, Kurlansky P, Ning Y, et al. Continuous near-infrared reflectance spectroscopy monitoring to guide distal perfusion can minimize limb ischemia surgery for patients requiring femoral venoarterial extracorporeal life support. J Vasc Surg. 2023;77(5):1456-1465. doi:10.1016/j.jvs.2022.12.028 Sohn B, Lee H. Near-infrared spectroscopy for preventing limb ischemia in extracorporeal membrane oxygenation. Artif Organs. 2025. doi:10.1111/aor.14978 Kim DJ, Cho YJ, Park SH, et al. Near-infrared spectroscopy monitoring for early detection of limb ischemia in patients on veno-arterial extracorporeal membrane oxygenation. ASAIO J. 2017;63(5):613-617. doi:10.1097/MAT.0000000000000532 Matthews R, Surti A, Bahroloomi D, et al. Contemporary practices and limb outcomes in peripheral venoarterial extracorporeal membrane oxygenation at a high-volume single institution. J Vasc Surg. 2026;83(4):1234-1242. doi:10.1016/j.jvs.2025.10.015 Son AY, Khanh LN, Joung HS, et al. Limb ischemia and bleeding in patients requiring venoarterial extracorporeal membrane oxygenation. J Vasc Surg. 2021;73(2):669-676. doi:10.1016/j.jvs.2020.05.073 Chanan EL, Bingham N, Smith DE, Nunnally ME. Early detection, prevention, and management of acute limb ischemia in adults supported with venoarterial extracorporeal membrane oxygenation. J Cardiothorac Vasc Anesth. 2020;34(11):3125-3132. doi:10.1053/j.jvca.2020.03.005 ★ Seto AH, Estep JD, Tayal R, et al. SCAI position statement on best practices for percutaneous axillary arterial access and training. J Soc Cardiovasc Angiogr Interv. 2022;1(4):100365. doi:10.1016/j.jscai.2022.100365 Davis HD, Habarth-Morales TE, Messa CA, Broach RB, Lin IC. Extracorporeal membrane oxygenation-associated compartment syndrome: review of a national database. J Surg Res. 2024;298:61-68. doi:10.1016/j.jss.2024.03.024 ★ Writing Committee Members, Gornik HL, Aronow HD, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease. J Am Coll Cardiol. 2024;83(24):2497-2604. doi:10.1016/j.jacc.2024.02.013 Juo YY, Skancke M, Sanaiha Y, et al. Efficacy of distal perfusion cannulae in preventing limb ischemia during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Artif Organs. 2017;41(11):E263-E273. doi:10.1111/aor.12942 Balthazar T, Vandenbriele C, Verbrugge FH, et al. Managing patients with short-term mechanical circulatory support: JACC review topic of the week. J Am Coll Cardiol. 2021;77(9):1243-1256. doi:10.1016/j.jacc.2020.12.054 Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America guideline on acute mechanical circulatory support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003 Lorusso R, Whitman G, Milojevic M, et al. 2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients. J Thorac Cardiovasc Surg. 2021;161(4):1287-1331. doi:10.1016/j.jtcvs.2020.09.045 Wong JK, Smith TN, Pitcher HT, Hirose H, Cavarocchi NC. Cerebral and lower limb near-infrared spectroscopy in adults on extracorporeal membrane oxygenation. Artif Organs. 2012;36(8):659-667. doi:10.1111/j.1525-1594.2012.01496.x Cuculi F, Burkart P, Cioffi G, et al. Manual compression versus MANTA device for access management after Impella removal on the ICU. Sci Rep. 2022;12(1):14044. doi:10.1038/s41598-022-18316-z

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 sheaths A stiff guidewire  Sequential dilators Venous 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 tibial artery Surgical cutdown kit (backup) Ultrasound for vascular access guidance Pre-close devices (Perclose ProGlide) if percutaneous decannulation is planned ECMO cannulations may occur in the cath lab, ICU, emergency department, or in the field. Having a mobile ECMO cart with all equipment pre-assembled allows rapid deployment to any location. Distal Perfusion Cannula (DPC) The DPC should be considered standard of care for all patients receiving femoral VA-ECMO. Limb ischemia historically occurred in ~17% of peripheral VA-ECMO patients, with 10% requiring fasciotomy and ~5% requiring amputation. A meta-analysis by Juo et al. (2017) demonstrated that prophylactic DPC placement reduced the incidence of limb ischemia from 25.4% to 9.7% (RR, 0.41; 95% CI, 0.26–0.65). A subsequent meta-analysis by Marbach et al. (2022) confirmed this finding (OR 0.31; 95% CI 0.21–0.47; p<0.001). A multicenter registry study (Lee et al., 2023) further showed that prophylactic DPC was associated with lower 30-day mortality (33.1% vs. 53.2%; RR 0.68). Technique: A 6–8F antegrade sheath is placed in the ipsilateral SFA and connected to the arterial limb of the ECMO circuit via a Y-connector (using a male-to-male connection), diverting a portion of oxygenated blood to the distal limb. Dr. Gage’s tip: Perform the antegrade SFA stick at the same time as the retrograde CFA stick, before any cannulas are placed. Using ultrasound, obtain retrograde CFA access with the right hand, leave the micropuncture wire, then quickly scan distally to the SFA and obtain antegrade access with the left hand. Place 6F sheaths over both wires. This provides the best ultrasound view (no large cannula obstructing), preserves SFA flow for the antegrade stick. Exception: do not do this during active ECPR — proceed directly to cannulation and obtain the DPC later once the patient is stabilized. Monitoring: Hourly Doppler checks of distal pulses, near-infrared spectroscopy (NIRS) of the cannulated vs. non-cannulated leg, and clinical assessment (pallor, temperature, capillary refill). Elevated CPK or lactate are late and concerning findings. Decision-Making on Mechanical LV Unloading VA-ECMO increases LV afterload via retrograde aortic flow. The decision to add an unloading device depends on the underlying etiology, expected recovery timeframe, and real-time hemodynamic assessment. Key assessment parameters: Arterial pulsatility: A pulse pressure ≥20 mmHg suggests some native cardiac output and aortic valve opening. If pulsatility is absent or minimal, LV distension and stasis are more likely. Echocardiographic assessment: Aortic valve opening with each cardiac cycle, LV cavity size, presence of spontaneous echo contrast or thrombus, and degree of mitral regurgitation. In practice, most patients do not meet the 20 mmHg pulse pressure threshold immediately after cannulation, so many operators deploy an upfront unloading strategy (IABP or Impella) when the patient is already in the cath lab — avoiding the need for repeated transport on ECMO. The goal of ECMO support also matters: if the goal is LV recovery (e.g., myocarditis), aggressive unloading to rest the myocardium may be more important than if the goal is bridge to transplant or durable VAD. Unloading options: IABP (reduces afterload, improves coronary perfusion), Impella (directly unloads LV), transseptal LA cannulation, or atrial septostomy. Anticoagulation Unfractionated heparin (UFH) is the standard anticoagulant for VA-ECMO. The ELSO guidelines (2017) and ISHLT/HFSA guideline (2023) recommend an initial bolus of 50–100 U/kg at the time of cannulation. Timing: Administer heparin after vascular access is obtained but before dilation and cannula insertion. In the episode, Dr. Gage’s protocol uses 70 U/kg (e.g., 70 kg × 70 U/kg = ~5,000 U). Maintenance anticoagulation targets (significant institutional variability exists): ACT: 180–220 seconds (ELSO recommendation) aPTT: 1.5–2.5× baseline (approximately 50–75 seconds) Anti-Xa: 0.3–0.7 IU/mL Alternatives for heparin-induced thrombocytopenia (HIT): Bivalirudin or argatroban, monitored by aPTT 50–60 seconds. The balance between thrombotic and hemorrhagic complications is critical. The ECMO circuit’s nonendothelial surface triggers an inflammatory and prothrombotic response with consumptive coagulopathy, while simultaneously causing platelet dysfunction and von Willebrand factor proteolysis, creating a pro-hemorrhagic phenotype. Cannulation Procedure: Step-by-Step Step 1 — Access: Using ultrasound guidance, obtain femoral arterial and venous access with micropuncture needles. Ultrasound-guided access is strongly preferred to reduce vascular complications, though in emergencies (ECPR) it may not always be feasible. Step 2 — Wire exchange: Exchange the micropuncture wire for a supportive guidewire through the micropuncture sheath (after obtaining a femoral angiogram if in the cath lab). Step 3 — Antegrade DPC access (if time permits): Before upsizing, obtain antegrade SFA access for the distal perfusion catheter (see DPC section above for Dr. Gage’s simultaneous access technique). Place a 6–7F sheath. Step 4 — Heparin administration: Give weight-based UFH bolus (50–100 U/kg) after access, before dilation. Step 5 — Pre-close (if percutaneous decannulation planned): Deploy two Perclose ProGlide devices at each cannulation site before upsizing. Step 6 — Serial dilation: Dilate the tract sequentially. Consider upsizing the dilator by 1–2F above the intended venous cannula size (e.g., a 27F dilator for a 25F venous cannula) to facilitate smooth insertion. Dr. Jumean’s pro-tip: after removing each dilator, briefly advance and withdraw the wire to confirm it is not kinked or stuck. Step 7 — Cannula insertion: Place the venous drainage cannula (23–25F multi-stage) with the tip at the SVC-RA junction. Place the arterial return cannula (15–20F single-stage) with the tip in the descending aorta or common iliac artery. Step 8 — Clamp and connect: Clamp both cannulas. Perform a wet connection (to avoid air entrainment) to the ECMO circuit tubing. The perfusionist initiates flow. Step 9 — Confirm positioning: Verify cannula tip positions with fluoroscopy and/or echocardiography. Assess for adequate flows, hemodynamic improvement, and distal limb perfusion. Step 10 — Connect DPC: Connect the antegrade perfusion sheath to the arterial limb of the circuit via a Y-connector with a male-to-male connection. Decannulation and Vascular Closure Decannulation strategy is program-dependent and evolving. Two main approaches exist: Surgical cutdown: Traditional approach. The femoral vessels are exposed, cannulas removed, and vessels repaired under direct vision. Advantages: direct visualization, ability to perform Fogarty thrombectomy (significant thrombus burden is common). Disadvantages: longer procedure time, higher groin infection rates (up to 19% vs. 2% with percutaneous), requires OR availability. Percutaneous decannulation: Increasingly adopted by interventional cardiologists. Two strategies: Pre-close technique: At the time of cannulation, two Perclose ProGlide devices are deployed at each site before upsizing. At decannulation, cannulas are removed and the pre-deployed sutures are tightened. Technical success rates of 91–95% have been reported, with lower groin infection rates and shorter procedure times compared with surgical cutdown. Post-close technique (no pre-close): Clamp both cannulas. Puncture the soft plastic portion of the cannula with a large-bore (16–18G) needle, wire through it with a stiff wire, remove the cannula over the wire. Options include: (a) deploy two Perclose devices sequentially; or (b) use a “two 8F sheath” technique — place an 8F sheath, insert two wires, remove the sheath, place an 8F sheath over each wire, and pre-close each separately. Key considerations for percutaneous decannulation: Document baseline pedal pulses before decannulation. Perform angiography before and after closure to confirm vessel patency and rule for stenosis/occlusion. Have a surgeon aware and available as backup. Maintain contralateral femoral access capability in case bailout intervention is needed. Failure risk is higher in patients with BMI ≥35 or cannulas inserted through the inguinal ligament or at the SFA bifurcation. Hybrid approach: Many patients transition from VA-ECMO to a durable device (e.g., Impella 5.5) in the OR, where surgeons perform decannulation and implantation of the new device simultaneously. In this scenario, an interventional cardiologist may assist by percutaneously closing the DPC site. Post-decannulation surveillance: Vascular complications after VA-ECMO are common — CT studies show up to 81% of patients have some vascular finding (thrombosis, stenosis, or bleeding) after decannulation. Routine vascular screening with duplex ultrasound or CT angiography is recommended. Late vascular complications (infection, limb-threatening ischemia) occur in ~8% of survivors and may present weeks to months after discharge. References Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for adults: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019;73(6):698-716. doi:10.1016/j.jacc.2018.11.038 Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America guideline on acute mechanical circulatory support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003 Juo YY, Skancke M, Sanaiha Y, et al. Efficacy of distal perfusion cannulae in preventing limb ischemia during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Artif Organs. 2017;41(11):E263-E273. doi:10.1111/aor.12942 Marbach JA, Faugno AJ, Pacifici S, et al. Strategies to reduce limb ischemia in peripheral venoarterial extracorporeal membrane oxygenation: a systematic review and meta-analysis. Int J Cardiol. 2022;361:77-84. doi:10.1016/j.ijcard.2022.04.084 Lee HH, Jang WJ, Ahn CM, et al. Association of prophylactic distal perfusion cannulation with mortality in patients receiving venoarterial extracorporeal membrane oxygenation. Am J Cardiol. 2023;207:418-425. doi:10.1016/j.amjcard.2023.07.149 Ezad SM, Ryan M, Donker DW, et al. Unloading the left ventricle in venoarterial ECMO: in whom, when, and how? Circulation. 2023;147(16):1237-1250. doi:10.1161/CIRCULATIONAHA.122.062371 Geller BJ, Sinha SS, Kapur NK, et al. Escalating and de-escalating temporary mechanical circulatory support in cardiogenic shock: a scientific statement from the American Heart Association. Circulation. 2022;146(6):e50-e68. doi:10.1161/CIR.0000000000001076 Randhawa VK, Al-Fares A, Tong MZY, et al. A pragmatic approach to weaning temporary mechanical circulatory support: a state-of-the-art review. JACC Heart Fail. 2021;9(9):664-673. doi:10.1016/j.jchf.2021.05.011 Kato C, Oakes M, Kim M, et al. Anticoagulation strategies in extracorporeal circulatory devices in adult populations. Eur J Haematol. 2021;106(1):19-31. doi:10.1111/ejh.13520 Martin-Tuffreau AS, Bagate F, Boukantar M, et al. Complete percutaneous angio-guided approach using preclosing for venoarterial extracorporeal membrane oxygenation implantation and explantation in patients with refractory cardiogenic shock or cardiac arrest. Crit Care. 2021;25(1):93. doi:10.1186/s13054-021-03522-8 Liu TX, Medina MG, McGregor R, et al. Percutaneous postclosure vs femoral arterial cutdown for venoarterial extracorporeal membrane cannulation sites. Ann Thorac Surg. 2026;121(1):233-238. doi:10.1016/j.athoracsur.2025.07.026 Hayakawa N, Tobita K, Kodera S, et al. Efficacy and safety of percutaneous venoarterial extracorporeal membrane oxygenation decannulation using endovascular balloon dilation and Perclose ProGlide closure device: results from the multicenter SKYLINE study. Ann Vasc Surg. 2023;96:357-364. doi:10.1016/j.avsg.2023.03.025 Ng JJ, Lee SHT, Lim JKW, et al. Percutaneous decannulation of venoarterial extracorporeal membrane oxygenation using the Manta vascular closure device: a systematic review and meta-analysis. Artif Organs. 2023;47(9):1431-1441. doi:10.1111/aor.14554 Jia D, Yang IX, Ling RR, et al. Vascular complications of extracorporeal membrane oxygenation: a systematic review and meta-regression analysis. Crit Care Med. 2020;48(12):e1269-e1277. doi:10.1097/CCM.0000000000004688 Djavidi N, Boussouar S, Duceau B, et al. Vascular complications after venoarterial extracorporeal membrane oxygenation support: a CT study. Crit Care Med. 2025;53(1):e96-e108. doi:10.1097/CCM.0000000000006476 Bidar F, Lancelot A, Lebreton G, et al. Venous or arterial thromboses after venoarterial extracorporeal membrane oxygenation support: frequency and risk factors. J Heart Lung Transplant. 2021;40(4):307-315. doi:10.1016/j.healun.2020.12.007 Fisser C, Armbrüster C, Wiest C, et al. Arterial and venous vascular complications in patients requiring peripheral venoarterial extracorporeal membrane oxygenation. Front Med. 2022;9:960716. doi:10.3389/fmed.2022.960716 Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet. 2020;396(10245):199-212. doi:10.1016/S0140-6736(20)31047-3 Rihal CS, Naidu SS, Givertz MM, et al. 2015 SCAI/ACC/HFSA/STS clinical expert consensus statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care. J Am Coll Cardiol. 2015;65(19):e7-e26. doi:10.1016/j.jacc.2015.03.036 Lanoiselée J, Mourer J, Jungling M, et al. Heparin dosing regimen optimization in veno-arterial extracorporeal membrane oxygenation: a pharmacokinetic analysis. Pharmaceutics. 2024;16(6):770. doi:10.3390/pharmaceutics16060770 Goldberg JB, Giri J, Kobayashi T, et al. Surgical management and mechanical circulatory support in high-risk pulmonary embolisms: a scientific statement from the American Heart Association. Circulation. 2023;147(9):e628-e647. doi:10.1161/CIR.0000000000001117 Banks CA, Blakeslee-Carter J, Nkie V, et al. Occurrence, predictors, and management of late vascular complications following extracorporeal membrane oxygenation. J Vasc Surg. 2024;80(3):864-872.e1. doi:10.1016/j.jvs.2024.04.041

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/cardiotoxicity Massive pulmonary embolism (PE): Bridge to thrombectomy or thrombolysis Extracorporeal cardiopulmonary resuscitation (ECPR): Refractory cardiac arrest Procedural 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 insufficiency Absolute: 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 Different Indications The Extracorporeal Life Support Organization (ELSO) registry is the largest source of VA-ECMO outcomes data. Overall survival to hospital discharge for adult cardiac VA-ECMO is approximately 42% (Combes et al., Lancet 2020; 19,627 patients). Survival has remained relatively stable despite increasing utilization. Survival varies significantly by underlying diagnosis (Danial et al., JACC 2023; Guglin et al., JACC 2019): Fulminant myocarditis: ~65% survival (highest) Primary graft failure after heart transplant: >50% Drug overdose/cardiotoxicity: >50% AMI-related CS: ~35–47% Postcardiotomy shock: ~25–35% survival (poorest outcomes) ECPR in adults: ~29.5% survival (ELSO 2022 report) Pre-ECMO risk factors for poor outcomes: older age, higher BMI, renal/hepatic/CNS dysfunction, longer pre-ECMO mechanical ventilation, elevated lactate, reduced prothrombin activity, and pre-ECMO cardiac arrest. The SAVE (Survival After Veno-Arterial ECMO) score is the most widely cited risk prediction tool, incorporating diagnosis, age, weight, organ function, and pre-ECMO intubation duration. AUROC 0.68 in derivation, 0.90 in external validation (Schmidt et al., Eur Heart J 2015). Key RCT data: ECLS-SHOCK (NEJM 2023): Largest RCT; AMI-CS patients randomized to early VA-ECMO vs. standard care. No difference in 30-day mortality (47.8% vs. 49.0%; RR 0.98; p=0.81). More bleeding/vascular complications with ECMO. ECMO-CS (Circulation 2023): 117 patients with rapidly deteriorating/severe CS (multiple etiologies) randomized to immediate VA-ECMO vs. early conservative strategy. No difference in composite primary endpoint at 30 days (63.8% vs. 71.2%; HR 0.72; p=0.21). Post-hoc analyses suggest potential benefit in patients with CI <2.2 L/min/m², SvO2 <60%, or elevated pCO2 gap (Ostadal et al., Crit Care 2025). IPD meta-analysis of four RCTs (Zeymer et al., Lancet 2023): No mortality benefit with routine VA-ECMO in AMI-CS; more complications in the device group. ECPR data: ARREST (Lancet 2020): Refractory OHCA with VF; stopped early for superiority — 43% vs. 7% survival to discharge. Prague OHCA (JAMA 2022): Shockable and non-shockable rhythms; 180-day neurologically favorable survival 31.5% vs. 22.0% (p=0.09); 30-day neurologic recovery significantly better (30.6% vs. 18.2%; p=0.02). INCEPTION (NEJM 2023): Multicenter; refractory OHCA with ventricular arrhythmias; 30-day favorable neurologic outcome 20% vs. 16% (OR 1.4; p=0.52). Longer cannulation times and lower-volume centers may have contributed to neutral results. Pooled analysis of ARREST + Prague OHCA (Belohlavek et al., EClinicalMedicine 2023): Significant benefit for ECPR in shockable rhythms — 47.1% vs. 28.3% neurologically favorable survival at 180 days (NNT = 5). The 2023 AHA Focused Update on Adult ACLS (Circulation 2024) gives a Class 2b (conditional) recommendation for ECPR in select patients with refractory OHCA at experienced, high-volume centers. LV Unloading on VA-ECMO VA-ECMO increases LV afterload via retrograde aortic flow. The concern: increased afterload → elevated LVEDP/volume → increased myocardial O2 demand → worsened LV function → pulmonary congestion and LV stasis. The nuance: The venous drainage cannula directly drains the right heart, reducing RA preload and RV stroke volume. On the ascending limb of the Frank-Starling curve, decreased RV preload → less LV filling, partially counterbalancing the afterload increase. The hemodynamic response depends on loading conditions and contractility of both ventricles (University of Minnesota group, in vivo data). LV unloading strategies: IABP (reduces afterload, improves coronary perfusion), micro-axial flow pump/Impella (directly unloads LV), transseptal LA cannulation, atrial septostomy, surgical LV apical drainage. Observational data (Schrage et al., Circulation 2020): LV unloading associated with lower mortality in a multicenter cohort. RCTs have not confirmed the benefit of routine unloading: EARLY-UNLOAD (Circulation 2023): Early LV unloading vs. conventional approach — no mortality difference (46.6% vs. 44.8%; p=0.94). EVOLVE-ECMO (Eur J Heart Fail 2023): Early LA venting vs. conventional — no difference in ECMO weaning or survival. Practical consideration: Many operators deploy upfront unloading because the patient is already in the cath lab, avoiding repeated transport on ECMO. The decision should also factor in the goal of ECMO (LV recovery vs. bridge to replacement therapy). The Role of the Shock Team Shock teams are multidisciplinary groups (interventional cardiology, heart failure/transplant, cardiac surgery, critical care, and anesthesiology) that facilitate early recognition, evaluation, and management of CS. Multicenter data (Papolos et al., JACC 2021; >1,200 CS admissions): Centers with shock teams had ~28% lower adjusted odds of CICU mortality (adjusted OR 0.72; 95% CI 0.55–0.95; p=0.019). Mechanisms of benefit: earlier identification before multi-organ dysfunction, increased PAC use for hemodynamic phenotyping, more appropriate/timely MCS deployment, streamlined care delivery. The 2025 ACC Expert Consensus Statement on Cardiogenic Shock (Sinha et al., JACC 2025) strongly recommends a standardized, interdisciplinary, team-based approach and early contact with regional Level 1 CS centers. Consent for VA-ECMO: Risks, Benefits, Alternatives Consent is frequently obtained from a surrogate (POA/next of kin) because patients are often too ill to participate. Key elements: Simple description: VA-ECMO is full life support that does the work of the heart and lungs for days to weeks. Indication: Support the heart and maintain organ function while treating the underlying cause. Procedure: Large cannulas placed in the groin vessels, connected to an external machine. Risks: Life-threatening bleeding, stroke, limb ischemia, infection. Overall survival <50%, though individual prognosis varies by underlying condition. Benefits: Time for the heart to recover, for additional treatments, and for organ preservation. If no recovery, may bridge to durable VAD or transplant. Alternatives: Continued medical therapy with vasoactive medications. Expectations: Period of attempted stabilization → best case: recovery. If not, ECMO maintained days to weeks while evaluating advanced therapies. Typical course: 1–3 weeks in cardiac ICU, potentially extended rehabilitation. Understanding the patient’s premorbid condition and wishes is imperative. An ECMO coordinator can serve as an early information gatherer, contacting the POA to learn about baseline condition and preferences before the physician seeks formal consent. Discontinuation should be discussed upfront. The “bridge to nowhere” scenario raises profound ethical challenges; early palliative care and ethics consultation involvement is recommended. References ★ Combes A, Price S, Slutsky AS, Brodie D. Temporary circulatory support for cardiogenic shock. Lancet. 2020;396(10245):199-212. doi:10.1016/S0140-6736(20)31047-3 ★ Tonna JE, Boonstra PS, MacLaren G, et al. Extracorporeal Life Support Organization Registry International Report 2022: 100,000 survivors. ASAIO J. 2024;70(2):131-143. doi:10.1097/MAT.0000000000002128 ★ Thiele H, Zeymer U, Akin I, et al. Extracorporeal life support in infarct-related cardiogenic shock. N Engl J Med. 2023;389(14):1286-1297. doi:10.1056/NEJMoa2307227 ★ Ostadal P, Rokyta R, Karasek J, et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation. 2023;147(6):454-464. doi:10.1161/CIRCULATIONAHA.122.062949 Ostadal P, Rokyta R, Karasek J, et al. Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: 1-year outcomes of the ECMO-CS trial. Eur J Heart Fail. 2025;27(1):30-36. doi:10.1002/ejhf.3398 Ostadal P, Vondrakova D, Rokyta R, et al. Cardiac index, SvO2 or pCO2 gap may determine benefit from ECMO in cardiogenic shock: post-hoc analysis of the ECMO-CS trial. Crit Care. 2025;29(1):303. doi:10.1186/s13054-025-05513-5 ★ Zeymer U, Freund A, Hochadel M, et al. Venoarterial extracorporeal membrane oxygenation in patients with infarct-related cardiogenic shock: an individual patient data meta-analysis of randomised trials. Lancet. 2023;402(10410):1338-1346. doi:10.1016/S0140-6736(23)01607-0 ★ Yannopoulos D, Bartos J, Raveendran G, et al. Advanced reperfusion strategies for patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (ARREST). Lancet. 2020;396(10265):1807-1816. doi:10.1016/S0140-6736(20)32338-2 ★ Belohlavek J, Smalcova J, Rob D, et al. Effect of intra-arrest transport, extracorporeal cardiopulmonary resuscitation, and immediate invasive assessment and treatment on functional neurologic outcome in refractory out-of-hospital cardiac arrest (Prague OHCA). JAMA. 2022;327(8):737-747. doi:10.1001/jama.2022.1025 ★ Suverein MM, Delnoij TSR, Lorusso R, et al. Early extracorporeal CPR for refractory out-of-hospital cardiac arrest (INCEPTION). N Engl J Med. 2023;388(4):299-309. doi:10.1056/NEJMoa2204511 Belohlavek J, Yannopoulos D, Smalcova J, et al. Intraarrest transport, extracorporeal cardiopulmonary resuscitation, and early invasive management in refractory out-of-hospital cardiac arrest: an individual patient data pooled analysis of two randomised trials. EClinicalMedicine. 2023;59:101988. doi:10.1016/j.eclinm.2023.101988 Supady A, Bělohlávek J, Combes A, et al. Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest. Lancet Respir Med. 2025;13(9):843-856. doi:10.1016/S2213-2600(25)00122-5 ★ Schmidt M, Burrell A, Roberts L, et al. Predicting survival after ECMO for refractory cardiogenic shock: the Survival After Veno-Arterial-ECMO (SAVE)-score. Eur Heart J. 2015;36(33):2246-2256. doi:10.1093/eurheartj/ehv194 ★ Danial P, Olivier ME, Bréchot N, et al. Association between shock etiology and 5-year outcomes after venoarterial extracorporeal membrane oxygenation. J Am Coll Cardiol. 2023;81(9):897-909. doi:10.1016/j.jacc.2022.12.018 ★ Guglin M, Zucker MJ, Bazan VM, et al. Venoarterial ECMO for adults: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019;73(6):698-716. doi:10.1016/j.jacc.2018.11.038 ★ Papolos AI, Kenigsberg BB, Berg DD, et al. Management and outcomes of cardiogenic shock in cardiac ICUs with versus without shock teams. J Am Coll Cardiol. 2021;78(13):1309-1317. doi:10.1016/j.jacc.2021.07.044 ★ Sinha SS, Morrow DA, Kapur NK, Kataria R, Roswell RO. 2025 Concise clinical guidance: an ACC expert consensus statement on the evaluation and management of cardiogenic shock. J Am Coll Cardiol. 2025;85(16):1618-1641. doi:10.1016/j.jacc.2025.02.018 ★ Schrage B, Becher PM, Bernhardt A, et al. Left ventricular unloading is associated with lower mortality in patients with cardiogenic shock treated with venoarterial extracorporeal membrane oxygenation. Circulation. 2020;142(22):2095-2106. doi:10.1161/CIRCULATIONAHA.120.048792 Kim MC, Lim Y, Lee SH, et al. Early left ventricular unloading or conventional approach after venoarterial extracorporeal membrane oxygenation: the EARLY-UNLOAD randomized clinical trial. Circulation. 2023;148(20):1570-1581. doi:10.1161/CIRCULATIONAHA.123.066179 Park H, Yang JH, Ahn JM, et al. Early left atrial venting versus conventional treatment for left ventricular decompression during venoarterial extracorporeal membrane oxygenation support: the EVOLVE-ECMO randomized clinical trial. Eur J Heart Fail. 2023;25(11):2037-2046. doi:10.1002/ejhf.3014 Russo JJ, Aleksova N, Pitcher I, et al. Left ventricular unloading during extracorporeal membrane oxygenation in patients with cardiogenic shock. J Am Coll Cardiol. 2019;73(6):654-662. doi:10.1016/j.jacc.2018.10.085 Perman SM, Elmer J, Maciel CB, et al. 2023 American Heart Association focused update on adult advanced cardiovascular life support. Circulation. 2024;149(5):e254-e273. doi:10.1161/CIR.0000000000001194 Thiele H, Hassager C. Cardiogenic shock. N Engl J Med. 2026;394(1):62-77. doi:10.1056/NEJMra2312086 Lüsebrink E, Binzenhöfer L, Adamo M, et al. Cardiogenic shock. Lancet. 2024;404(10466):2006-2020. doi:10.1016/S0140-6736(24)01818-X Enumah ZO, Carrese J, Choi CW. The ethics of extracorporeal membrane oxygenation: revisiting the principles of clinical bioethics. Ann Thorac Surg. 2021;112(1):61-66. doi:10.1016/j.athoracsur.2020.08.045 Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America guideline on acute mechanical circulatory support. J Card Fail. 2023;29(3):304-374. doi:10.1016/j.cardfail.2022.11.003

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