ECMO Weaning Strategies to Optimize Outcomes

Survival to discharge in patients presenting with cardiogenic shock who are managed using extracorporeal membrane oxygenation (ECMO) remains low at ~50%. This speaks to the acuity and severity of individuals being placed on ECMO, as well as the time dependent risk for complications associated with this therapy. Although some patients are able to be weaned from ECMO to either recovery, left ventricular assist device or heart transplantation, other individuals do not survive after device removal, suggesting that current protocols may not be identifying individuals with enough intrinsic cardiac recovery to maintain adequate end-organ perfusion. The decision to wean an individual from ECMO is complex and entails several factors that are dynamic and evolving daily while on full circulatory support. Objective clinical, hemodynamic and biological markers are needed to be controlled prior to trialing device weans but many times the decision relies on clinical experience and intuition. The purpose of this chapter will be to: (1) outline the survival and risks associated with ECMO which encourages early weaning trials and (2) identify patient factors related to either successful weaning or early referral for durable mechanical support or transplant.