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Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities
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Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Pulmonology".

Deadline for manuscript submissions: 15 May 2025 | Viewed by 13470

Special Issue Editor

Dr. Yutaka Fujii

E-Mail Website
Guest Editor
Department of Clinical Engineering and Medical Technology, Niigata University of Health and Welfare, Niigata 950-3198, Japan
Interests: extracorporeal membrane oxygenation (ECMO); cardiopulmonary bypass; diabetes; insulin resistance; metabolism; hypertension; inflammation; cardiac function; cardiovascular disease; blood pressure

Special Issue Information

Dear Colleagues,

Extracorporeal membrane oxygenation (ECMO) has gained popularity in various clinical emergencies and intensive care settings as a rescue tool for severe circulatory and/or respiratory failure. This proven rescue therapy is being increasingly used, but its further development and application remain challenging. The use of ECMO has entered a new phase during the COVID-19 pandemic. Managing ECMO is challenging due to the risks and possibilities faced by patients.

In this Special Issue, we plan to collect information on important ECMO-related complications, including, but not limited to, cardiovascular–pulmonary disease-related acute organ support and chronic support, as well as the publication of articles and reviews on emerging challenges and new strategies for further communication.

Dr. Yutaka Fujii
Guest Editor

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Keywords

  • extracorporeal membrane oxygenation (ECMO)
  • clinical emergencies
  • intensive care
  • respiratory failure
  • COVID-19
  • cardiovascular–pulmonary disease
  • organ support
  • challenges
  • strategies
  • complications
  • acute respiratory distress syndrome (ARDS)
  • cardiopulmonary bypass
  • cardiac function
  • basic research

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Published Papers (8 papers)

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Research

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11 pages, 7582 KiB  
Article
Staying in Place: In Vitro Comparison of Extracorporeal Membrane Oxygenation Cannula Fixation for Dislodgment Prevention
by Roxana Moayedifar, Johanna Schachl, Markus Königshofer, Martin Stoiber, Julia Riebandt, Daniel Zimpfer and Thomas Schlöglhofer
J. Clin. Med. 2025, 14(5), 1712; https://doi.org/10.3390/jcm14051712 - 4 Mar 2025
Viewed by 208
Abstract
Background/Objectives: Secure large-bore cannula insertion is critical for effective extracorporeal membrane oxygenation (ECMO), as inadequate fixation can lead to complications such as infection, dislodgment, and life-threatening events. With inconsistent guidelines for ECMO line management, this study compares the effectiveness of traditional suture [...] Read more.
Background/Objectives: Secure large-bore cannula insertion is critical for effective extracorporeal membrane oxygenation (ECMO), as inadequate fixation can lead to complications such as infection, dislodgment, and life-threatening events. With inconsistent guidelines for ECMO line management, this study compares the effectiveness of traditional suture fixation to an adhesive securement method in the prevention of ECMO cannula dislodgment using an in vitro model. Methods: Porcine skin and muscle tissue sections were prepared and mounted in a custom holder. A 21F venous ECMO cannula was inserted using a modified Seldinger technique. Three fixation methods were randomly compared: (1) three silk sutures, and (2a) one silk suture with a CathGrip adhesive anchoring device. In addition, a sub-analysis was performed using (2b) the Hollister adhesive anchoring device. A uniaxial testing machine simulated 50 mm cannula dislodgment, measuring tensile forces at 12.5, 25, and 50 mm dislodgment points. Results: A total of 26 ECMO cannula fixations using sutures, 26 with adhesive CathGrip, six with a Hollister device, and three controls were tested across six porcine samples. Sutures demonstrated greater variability in force at maximum dislocation, with 27% rupturing at 50 mm. In contrast, CathGrip provided greater flexibility without tearing. The adhesive exhibited higher stiffness (2.38 N/mm vs. 2.09 N/mm, p < 0.001) and dislodgment energy (0.034 J vs. 0.032 J, p = 0.002) in the 0–5 mm range, while sutures showed greater stiffness in the 5–50 mm range (1.42 N/mm vs. 1.18 N/mm, p < 0.001). At larger displacements (25 mm and 50 mm) and in total energy absorption, no statistically significant differences were observed (p = 0.57). In a sub-analysis, the six fixations using the Hollister device exhibited higher variability and significantly lower dislodgment forces at 25 mm (p = 0.033) and 50 mm (p = 0.004) compared to the CathGrip device. Conclusions: This study suggests that adhesive anchoring methods, such as CathGrip, may provide comparable or potentially superior fixation strength to sutures for ECMO cannula stabilization under controlled conditions. However, further research, including clinical trials, is necessary to confirm these findings, evaluate long-term performance, and explore the implications for dislodgment risk and infection prevention in clinical practice. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities)
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11 pages, 2934 KiB  
Article
Investigation of Inflammatory Reduction During Extracorporeal Membrane Oxygenation Using a Novel Cytokine Adsorption Column: A Rat Model Study
by Kota Miki, Hiroaki Fujieda, Yoshiyuki Ueno, Toru Arakane and Yutaka Fujii
J. Clin. Med. 2025, 14(5), 1686; https://doi.org/10.3390/jcm14051686 - 2 Mar 2025
Viewed by 190
Abstract
Background: Cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) are widely used. Previous methods to reduce inflammation have shown inconsistent results. We developed a cytokine adsorption column using polymethyl methacrylate (PMMA) and investigated its anti-inflammatory effects during ECMO. Materials and Methods: Male Sprague–Dawley [...] Read more.
Background: Cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) are widely used. Previous methods to reduce inflammation have shown inconsistent results. We developed a cytokine adsorption column using polymethyl methacrylate (PMMA) and investigated its anti-inflammatory effects during ECMO. Materials and Methods: Male Sprague–Dawley rats were divided into three groups (seven rats in each group): SHAM, ECMO, and ECMO with PMMA (PMMA group). Experiments comprised 180 min of cannulation only in the SHAM group and 60 min of ECMO followed by 120 min of observation in the ECMO and PMMA groups. PMMA adsorption was conducted from 30 min after ECMO initiation to completion in the PMMA group. Blood parameters and cytokines were measured during experiments. Lung tissues were collected after the experiment for evaluation of tissue edema. Results: The PMMA group showed significantly lower levels of tumor necrosis factor alpha (TNF-α) and interleukin(IL)-6 compared to the ECMO group at 120 min after completing ECMO. However, there were no significant differences in IL-10 levels between the ECMO group and the PMMA group at the same time points. Lung edema incidence was significantly lower in the PMMA group. Conclusions: The PMMA column effectively suppressed systemic inflammatory reactions during ECMO. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities)
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11 pages, 1105 KiB  
Article
The Ventilatory Ratio as a Predictor of Successful Weaning from a Veno-Venous Extracorporeal Membrane Oxygenator
by Anna Fischbach, Steffen B. Wiegand, Julia Alexandra Simons, Liselotte Ammon, Rüdger Kopp, Guillermo Ignacio Soccoro Matos, Julio Javier Baigorri, Jerome C. Crowley and Aranya Bagchi
J. Clin. Med. 2024, 13(13), 3758; https://doi.org/10.3390/jcm13133758 - 27 Jun 2024
Viewed by 1921
Abstract
Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a critical intervention for patients with severe lung failure, especially acute respiratory distress syndrome (ARDS). The weaning process from ECMO relies largely on expert opinion due to a lack of evidence-based guidelines. The ventilatory ratio (VR), [...] Read more.
Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a critical intervention for patients with severe lung failure, especially acute respiratory distress syndrome (ARDS). The weaning process from ECMO relies largely on expert opinion due to a lack of evidence-based guidelines. The ventilatory ratio (VR), which correlates with dead space and mortality in ARDS, is calculated as [minute ventilation (mL/min) x arterial pCO2 (mmHg)]/[predicted body weight × 100 × 37.5]. Objectives: The aim of this study was to determine whether the VR alone can serve as a reliable predictor of safe or unsafe liberation from VV-ECMO in critically ill patients. Methods: A multicenter retrospective analysis was conducted, involving ARDS patients undergoing VV-ECMO weaning at Massachusetts General Hospital (January 2016 – December 2020) and at the University Hospital Aachen (January 2012–December 2021). Safe liberation was defined as no need for ECMO recannulation within 48 h after decannulation. Clinical parameters were obtained for both centers at the same time point: 30 min after the start of the SGOT (sweep gas off trial). Results: Of the patients studied, 83.3% (70/84) were successfully weaned from VV-ECMO. The VR emerged as a significant predictor of unsafe liberation (OR per unit increase: 0.38; CI: 0.17–0.81; p = 0.01). Patients who could not be safely liberated had longer ICU and hospital stays, with a trend towards higher mortality (38% vs. 13%; p = 0.05). Conclusions: The VR may be a valuable predictor for safe liberation from VV-ECMO in ARDS patients, with higher VR values associated with an elevated risk of unsuccessful weaning and adverse clinical outcomes. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities)
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9 pages, 357 KiB  
Article
Comparing Outcomes of Post-Cardiotomy Cardiogenic Shock Patients: On-Site Cannulation vs. Retrieval for V-A ECMO Support
by Mircea R. Mihu, Ahmed M. El Banayosy, Michael D. Harper, Kaitlyn Cain, Marc O. Maybauer, Laura V. Swant, Joseph M. Brewer, Robert S. Schoaps, Ammar Sharif, Clayne Benson, Daniel R. Freno, Marshall T. Bell, John Chaffin, Charles C. Elkins, David W. Vanhooser and Aly El Banayosy
J. Clin. Med. 2024, 13(11), 3265; https://doi.org/10.3390/jcm13113265 - 31 May 2024
Viewed by 1024
Abstract
Background: Post-cardiotomy cardiogenic shock (PCCS) remains a life-threatening complication after cardiac surgery. Extracorporeal membrane oxygenation (ECMO) represents the mainstay of mechanical circulatory support for PCCS; however, its availability is limited to larger experienced centers, leading to a mismatch between centers performing cardiac surgery [...] Read more.
Background: Post-cardiotomy cardiogenic shock (PCCS) remains a life-threatening complication after cardiac surgery. Extracorporeal membrane oxygenation (ECMO) represents the mainstay of mechanical circulatory support for PCCS; however, its availability is limited to larger experienced centers, leading to a mismatch between centers performing cardiac surgery and hospitals offering ECMO management beyond cannulation. We sought to evaluate the outcomes and complications of PCCS patients requiring veno-arterial (V-A) ECMO cannulated at our hospital compared to those cannulated at referral hospitals. Methods: A retrospective analysis of PCCS patients requiring V-A ECMO was conducted between October 2014 to December 2022. Results: A total of 121 PCCS patients required V-A ECMO support, of which 62 (51%) patients were cannulated at the referring institutions and retrieved (retrieved group), and 59 (49%) were cannulated at our hospital (on-site group). The baseline demographics and pre-ECMO variables were similar between groups, except retrieved patients had higher lactic acid levels (retrieved group: 8.5 mmol/L ± 5.8 vs. on-site group: 6.6 ± 5; p = 0.04). Coronary artery bypass graft was the most common surgical intervention (51% in the retrieved group vs. 47% in the on-site group). There was no difference in survival-to-discharge rates between the groups (45% in the retrieved group vs. 51% in the on-site group; p = 0.53) or in the rate of patient-related complications. Conclusions: PCCS patients retrieved on V-A ECMO can achieve similar outcomes as those cannulated at experienced centers. An established network in a hub-and-spoke model is critical for the PCCS patients managed at hospitals without ECMO abilities to improve outcomes. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities)
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15 pages, 1664 KiB  
Article
Analysis of Patients with Severe ARDS on VV ECMO Treated with Inhaled NO: A Retrospective Observational Study
by Stefan Muenster, Jennifer Nadal, Jens-Christian Schewe, Heidi Ehrentraut, Stefan Kreyer, Christian Putensen and Stefan Felix Ehrentraut
J. Clin. Med. 2024, 13(6), 1555; https://doi.org/10.3390/jcm13061555 - 8 Mar 2024
Cited by 2 | Viewed by 1591
Abstract
(1) Background: This retrospective study focused on severe acute respiratory distress syndrome (ARDS) patients treated with veno-venous (VV) extracorporeal membrane oxygenation (ECMO) and who inhaled nitric oxide (NO) for pulmonary arterial hypertension (PAH) and/or right ventricular failure (RV failure). (2) Methods: [...] Read more.
(1) Background: This retrospective study focused on severe acute respiratory distress syndrome (ARDS) patients treated with veno-venous (VV) extracorporeal membrane oxygenation (ECMO) and who inhaled nitric oxide (NO) for pulmonary arterial hypertension (PAH) and/or right ventricular failure (RV failure). (2) Methods: Out of 662 ECMO-supported patients, 366 received VV ECMO, including 48 who inhaled NO. We examined the NO’s indications, dosing, duration, and the ability to lower PAH. We compared patients with and without inhaled NO in terms of mechanical ventilation duration, ECMO weaning, organ dysfunction, in-hospital mortality, and survival. (3) Results: Patients received 14.5 ± 5.5 ppm NO for 3 days with only one-third experiencing decreased pulmonary arterial pressure. They spent more time on VV ECMO, had a higher ECMO weaning failure frequency, and elevated severity scores (SAPS II and TIPS). A Kaplan–Meier analysis revealed reduced survival in the NO group. Multiple variable logistic regression indicated a twofold increased risk of death for ARDS patients on VV ECMO with NO. We observed no increase in continuous renal replacement therapy. (4) Conclusions: This study suggests that persistent PAH and/or RV failure is associated with poorer outcomes in severe ARDS patients on VV-ECMO, with an inhaled NO responder rate of only 30%, and it does not impact acute kidney failure rates. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities)
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Review

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15 pages, 1237 KiB  
Review
Vascular Complications in Extracorporeal Membrane Oxygenation—A Narrative Review
by Joseph P. Hart and Mark G. Davies
J. Clin. Med. 2024, 13(17), 5170; https://doi.org/10.3390/jcm13175170 - 31 Aug 2024
Cited by 2 | Viewed by 2217
Abstract
The establishment of a peripheral ECMO circuit can lead to significant arterial and venous complications in 10–30% of patients. Vascular complications, particularly acute limb ischemia, are associated with worsening overall outcomes. Limb ischemia occurs significantly more frequently in the early stages of VA [...] Read more.
The establishment of a peripheral ECMO circuit can lead to significant arterial and venous complications in 10–30% of patients. Vascular complications, particularly acute limb ischemia, are associated with worsening overall outcomes. Limb ischemia occurs significantly more frequently in the early stages of VA ECMO than in VV ECMO. Mechanisms of limb ischemia include arterial obstruction, cannulation injury, loss of pulsatile flow, thromboembolism, venous stasis from compressive obstruction with large venous cannulas, and systemic vasoconstriction due to shock and pharmacologic vasoconstriction. The care team may use several mitigation strategies to prevent limb ischemia. Arterial and venous complications can be mitigated by careful access site selection, minimizing cannula size, placement of distal perfusion and/or outflow catheter(s), and continuous NIRS monitoring. Rapid intervention, when ischemia or compartment syndrome occurs, can reduce limb loss but may not affect the mortality and morbidity of the ECMO patient in the long term due to their underlying conditions and the etiology of the ECMO need. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities)
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Other

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6 pages, 170 KiB  
Brief Report
A Survey to Quantify the Number and Structure of Extracorporeal Membrane Oxygenation Retrieval Programs in the United States
by Mircea R. Mihu, Laura V. Swant, Robert S. Schoaps, Caroline Johnson and Aly El Banayosy
J. Clin. Med. 2024, 13(6), 1725; https://doi.org/10.3390/jcm13061725 - 17 Mar 2024
Cited by 1 | Viewed by 2077
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) represents a potentially lifesaving support for respiratory and/or circulatory failure but its availability is limited to larger medical centers. A well-organized regional ECMO center with remote cannulation and retrieval ability can offer this intervention to patients [...] Read more.
(1) Background: Extracorporeal membrane oxygenation (ECMO) represents a potentially lifesaving support for respiratory and/or circulatory failure but its availability is limited to larger medical centers. A well-organized regional ECMO center with remote cannulation and retrieval ability can offer this intervention to patients treated at hospitals without ECMO. Information regarding the number and structure of ECMO retrieval programs in the United States is limited and there are no data regarding the size and structure of existing programs and which physician specialists perform cannulations and provide management. (2) Methods: We created a survey of 12 questions that was sent out to all adult US ECMO programs registered in the ELSO database. The data for the study were collected through an online survey instrument that was developed in Survey Monkey (Monkey Headquarters, Portland, OR). (3) Results: Approximately half of the centers that received the survey responded: 136 out of 274 (49.6%). Sixty-three centers (46%) have an ECMO retrieval program; 58 of these offer both veno-arterial (V-A) and veno-venous (V-V) ECMO, while 5 programs offer V-V ECMO rescue only. Thirty-three (52%) centers perform less than 10 ECMO retrievals per year, and only five (8%) hospitals can perform more than 50 ECMO rescues per year. Cardiothoracic surgeons perform the majority of the ECMO cannulations during retrievals in 30 programs (48%), followed by intensivists in eight (13%) programs and cardiologists in three (5%) centers. (4) Conclusions: Many ECMO centers offer ECMO retrievals; however, only a minority of the programs perform a large number of rescues per year. These cannulations are primarily performed by cardiothoracic surgeons. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities)
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14 pages, 1916 KiB  
Systematic Review
Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis
by Jonathan Jia En Boey, Ujwal Dhundi, Ryan Ruiyang Ling, John Keong Chiew, Nicole Chui-Jiet Fong, Ying Chen, Lukas Hobohm, Priya Nair, Roberto Lorusso, Graeme MacLaren and Kollengode Ramanathan
J. Clin. Med. 2024, 13(1), 64; https://doi.org/10.3390/jcm13010064 - 22 Dec 2023
Cited by 9 | Viewed by 3132
Abstract
Background: The use of extracorporeal membrane oxygenation (ECMO) for high-risk pulmonary embolism (HRPE) with haemodynamic instability or profound cardiogenic shock has been reported. Guidelines currently support the use of ECMO only in patients with cardiac arrest or circulatory collapse and in conjunction with [...] Read more.
Background: The use of extracorporeal membrane oxygenation (ECMO) for high-risk pulmonary embolism (HRPE) with haemodynamic instability or profound cardiogenic shock has been reported. Guidelines currently support the use of ECMO only in patients with cardiac arrest or circulatory collapse and in conjunction with other curative therapies. We aimed to characterise the mortality of adults with HRPE treated with ECMO, identify factors associated with mortality, and compare different adjunct curative therapies. Methods: We conducted a systematic review and meta-analysis, searching four international databases from their inception until 25 June 2023 for studies reporting on more than five patients receiving ECMO for HRPE. Random-effects meta-analyses were conducted. The primary outcome was in-hospital mortality. A subgroup analysis investigating the outcomes with curative treatment for HRPE was also performed. The intra-study risk of bias and the certainty of evidence were also assessed. This study was registered with PROSPERO (CRD42022297518). Results: A total of 39 observational studies involving 6409 patients receiving ECMO for HRPE were included in the meta-analysis. The pooled mortality was 42.8% (95% confidence interval [CI]: 37.2% to 48.7%, moderate certainty). Patients treated with ECMO and catheter-directed therapy (28.6%) had significantly lower mortality (p < 0.0001) compared to those treated with ECMO and systemic thrombolysis (57.0%). Cardiac arrest prior to ECMO initiation (regression coefficient [B]: 1.77, 95%-CI: 0.29 to 3.25, p = 0.018) and pre-ECMO heart rate (B: −0.076, 95%-CI: −0.12 to 0.035, p = 0.0003) were significantly associated with mortality. The pooled risk ratio when comparing mortality between patients on ECMO and those not on ECMO was 1.51 (95%-CI: 1.07 to 2.14, p < 0.01) in favour of ECMO. The pooled mortality was 55.2% (95%-CI: 47.7% to 62.6%), using trim-and-fill analysis to account for the significant publication bias. Conclusions: More than 50% of patients receiving ECMO for HRPE survive. While outcomes may vary based on the curative therapy used, early ECMO should be considered as a stabilising measure when treating patients with HRPE. Patients treated concurrently with systemic thrombolysis have higher mortality than those receiving ECMO alone or with other curative therapies, particularly catheter-directed therapies. Further studies are required to explore ECMO vs. non-ECMO therapies in view of currently heterogenous datasets. Full article
(This article belongs to the Special Issue Extracorporeal Membrane Oxygenation (ECMO): Clinical Challenges and Opportunities)
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