It is important to emphasize that indications are not based on prospective randomized clinical trials, and deployment is often driven by a clinical judgment that a patient is unstable with a risk of imminent death from cardiopulmonary failure. VA-ECMO is most frequently used in cases of shock with predominantly cardiogenic or obstructive physiology, and less commonly for distributive shock. Also, the advantage of VA-ECMO over other modalities of temporary MCS is that it provides robust biventricular, as opposed to univentricular support. Although it is not mandatory for VA-ECMO, concurrent respiratory failure may necessitate the choice of VA-ECMO over other temporary MCS options. In general, the indication for the use of VA-ECMO is circulatory failure, with or without concomitant respiratory failure. The overarching purpose of VA-ECMO is to provide temporary cardiopulmonary support for patients with refractory shock as a bridge to recovery from the acute incident or to allow for transition to, or candidacy for, long-term advanced therapies, such as surgical ventricular assist device or transplant. 6 A similar temporal increase in use of ECMO was reported in the ELSO Registry (Extracorporeal Life Support Organization) with CS (60.6%), cardiomyopathy (20.5%), and congenital defects (12.2%) being the top 3 indications among adults. 6, 7 An analysis of the Nationwide Inpatient Sample in the United States showed a 1511% increase in percutaneous device support (including ECMO) between 20. In the context of persistently poor CS outcomes and technological improvements in VA-ECMO, patients treated with cardiovascular mechanical circulatory support (MCS) have exponentially increased over the last decade ( Figure 1). 2–4 Heart failure is complicated by CS in 4% of hospitalized patients and is the second leading cause of CS (11%). 2, 3 After the publication of the SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock), an early invasive approach in MI-associated CS has been associated with a substantial decline in mortality, though not all studies have supported these conclusions, and contemporary mortality rates remain high (30% to 50%) in observational studies and randomized trials. 1 In the postrevascularization era, the incidence of MI-associated CS ranges from 4% to 10% and is declining in most longitudinal studies.
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