Veno-Arterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

Özet

The following article highlights various steps involved in initiating and maintaining veno-arterial extracorporeal membrane oxygenation in patients with cardiogenic shock.

Özet

Cardiogenic shock (CS) is a clinical condition characterized by inadequate tissue perfusion in the setting of low cardiac output. CS is the leading cause of death following acute myocardial infarction (AMI). Several temporary mechanical support devices are available for hemodynamic support in CS until clinical recovery ensues or until more definitive surgical procedures have been performed. Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) has evolved as a powerful treatment option for short-term circulatory support in refractory CS. In the absence of randomized clinical trials, the utilization of ECMO has been guided by clinical experience and based on data from registries and observational studies. Survival to hospital discharge with the use of VA-ECMO ranges from 28-67%. The initiation of ECMO requires venous and arterial cannulation, which can be performed either percutaneously or by surgical cutdown. Components of an ECMO circuit include an inflow cannula that draws blood from the venous system, a pump, an oxygenator, and an outflow cannula that returns blood to the arterial system. Management considerations post ECMO initiation include systemic anticoagulation to prevent thrombosis, left ventricle unloading strategies to augment myocardial recovery, prevention of limb ischemia with a distal perfusion catheter in cases of femoral arterial cannulation, and prevention of other complications such as hemolysis, air embolism, and Harlequin syndrome. ECMO is contraindicated in patients with uncontrolled bleeding, unrepaired aortic dissection, severe aortic insufficiency, and in futile cases such as severe neurological injury or metastatic malignancies. A multi-disciplinary shock team approach is recommended while considering patients for ECMO. Ongoing studies will evaluate whether the addition of routine ECMO improves survival in AMI patients with CS who undergo revascularization.

Giriş

Cardiogenic shock (CS) is a clinical condition characterized by inadequate tissue perfusion in the setting of low cardiac output. Despite advances in reperfusion therapy, acute myocardial infarction (AMI) remains the leading cause of CS. According to an analysis of the National Inpatient Sample (NIS) database, which collects data from approximately 20% of all United States hospitalizations, 55.4% of 144,254 CS cases between 2005 and 2014 were secondary to AMI¹. Other etiologies of CS include decompensated heart failure, fulminant myocarditis, post cardiotomy shock, and pulmonary embolism (PE). CS is associated with a high in-hospital mortality rate, ranging between 45-65%^1,2. Thus, rapid identification of CS and correction of reversible causes is critical in improving patient survival. For instance, the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) trial demonstrated that a strategy of early revascularization was associated with better survival at 6 months³ and 1 year⁴ compared to a strategy of initial medical stabilization in patients with CS complicating AMI.

Vasopressors and inotropes can be used to correct hypotension associated with CS, but neither have been shown to have any mortality benefit^5,6,7. Short-term mechanical circulatory support (MCS) devices, on the other hand, can provide hemodynamic support in patients with refractory CS as a bridge to recovery or as a bridge to more definitive therapy. The use of MCS has seen an increase in the recent decade; however, the incidence of CS hospitalizations has outpaced the utilization of MCS⁸. A declining trend in the utilization of intra-aortic balloon pumps (IABP) has been countered by a relative increase in the application of intravascular micro-axial left ventricular assist devices (LVAD) (e.g., Impella and TandemHeart) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

VA-ECMO can generate flows up to 4-6 L/min and its application in CS has gained significant popularity⁹. According to a global registry maintained by the Extracorporeal Life Support Organization (ELSO), the use of VA-ECMO increased from less than 500 runs per year prior to 2010 to 2,157 runs in 2015¹⁰. Nonetheless, VA-ECMO is a resource-intensive modality and requires round-the-clock availability of specialized equipment and trained staff. Therefore, patient selection is critically important prior to the initiation and maintenance of ECMO in order to improve outcomes and minimize adverse events. This article discusses the steps involved in initiation of VA-ECMO, post initiation maintenance, evidence behind its use,  and associated complications.

An ECMO circuit consists of an inflow cannula, centrifugal pump, oxygenator, and outflow cannula (Figure 1)¹¹. The inflow cannula is connected via tubing to a centrifugal pump, in which a spinning rotor generates flow and pressure. From the pump, blood flows to a membrane oxygenator where gas exchange takes place¹². Here, the hemoglobin is saturated with oxygen, and the degree of oxygenation is controlled by changing the flow rate and increasing or decreasing the fraction of inspired oxygen (FiO₂) supplied to the oxygenator. The removal of carbon dioxide is controlled by adjusting the sweep speed of the countercurrent gas passing through the oxygenator. A heat exchanger is usually attached to the oxygenator, and the temperature of blood returning to the body can thus be adjusted. From the oxygenator, blood is returned to the patient through an outflow cannula, either peripherally in the femoral artery or centrally in the aorta.

Protokol

This protocol follows the guidelines of the institutional human research ethics committee at the University of Nebraska Medical Center.

1. Patient selection

1. Consider VA-ECMO in patients with refractory CS as a bridge to recovery when the myocardial function is anticipated to improve following the initial insult, as a bridge to decision-making, or as a bridge to a more definitive therapy such as durable LVAD or cardiac transplantation when myocardial dysfunction is irreversible.
   NOTE: Various indications include CS secondary to AMI, end-stage heart failure, fulminant myocarditis, and cor pulmonale due to massive PE^{13,14,15,16,17}. Another area of growing use is in patients undergoing cardiac surgery who develop refractory post cardiotomy CS¹⁸.
2. Utilize VA-ECMO in selected patients with out-of-hospital cardiac arrest secondary to refractory ventricular fibrillation/ventricular tachycardia for cardiopulmonary support as a part of extracorporeal cardiopulmonary resuscitation (ECPR).
   NOTE: Limited evidence suggests that ECPR is associated with improved survival and is now incorporated in guidelines for CPR^19,20.
3. Refrain from using VA-ECMO in scenarios involving severe irreversible end-organ failure that limits survival, such as advanced malignancy, brain injury, aortic dissection, and when the patient's goals of care do not align with the use of MCS²¹.
   ​NOTE: Some relative contraindications include peripheral vascular disease hindering cannulation, uncontrolled bleeding, or a contraindication to the use of anticoagulants. Old age (>70 years) is not an absolute contraindication; however, this population historically has shown poor in-hospital survival compared to younger adults²².

2. Cannulation and initiation of VA-ECMO

1. Facilitate an interdisciplinary team-based discussion comprising advanced heart failure specialists, interventional cardiologists, cardio-thoracic surgeons, and critical care intensivists prior to initiating CS patients on VA-ECMO²³.
2. Perform the cannulation in the cardiac catheterization laboratory, the emergency department, or the intensive care unit for a percutaneous approach (peripheral cannulation), or in the operating room for a surgical approach (central cannulation)²⁴.
3. For the percutaneous approach, clean and prepare the access sites using an antiseptic solution such as chlorhexidine.
4. Under ultrasound guidance, obtain femoral venous access using a modified Seldinger technique with a needle and place a 5 Fr micro sheath²⁵.
5. Advance a flexible J tip guidewire (0.038 in x 180 cm) through the femoral vein into the inferior vena cava (IVC) and direct it to the right atrium.
6. Dilate the venous access site using sequential dilators to serially dilate the cannula passage, stepping up by one dilator (2 Fr sizes). Then place an appropriately sized venous cannula (single lumen).
   NOTE: The size of the cannula is determined based on the age, sex, and diameter of the vessel on the ultrasound, as well as the desired flows. The venous cannula is available in 21 Fr to 25 Fr sizes, and a 25 Fr cannula will usually suffice for most adults.
7. Confirm the tip of the venous cannula is at the junction of the intrahepatic portion of the IVC and the right atrium with fluoroscopy or plain X-ray.
8. Obtain arterial access, usually in the contralateral femoral artery, in a similar fashion using the modified Seldinger technique and then place a micro sheath (5 Fr).
9. Advance a flexible J-tip guidewire (0.038 in X 180 cm) or a stiff guidewire into the common femoral artery and then into the aorta.
10. Place an arterial cannula of appropriate size (15-21 Fr) after the progressive dilation of skin and subcutaneous tissue with dilators.
    NOTE: The cannula size is selected to provide a cardiac index of >2.4 L/min/m². A 19 Fr arterial cannula will provide sufficient support for most adults; however, for smaller females, a smaller size cannula should be used.
11. Place a distal perfusion catheter (DPC) for antegrade perfusion in the ipsilateral superficial femoral artery by the modified Seldinger technique usinga micro-puncture needle. Introduce a 5 Fr DPC and attach it to the side port of the arterial cannula using 6-7" extension tubing²⁶.
    NOTE: Progressively larger size arterial cannulae increase the risk of ischemic complications in the ipsilateral limb, especially in patients with underlying peripheral vascular disease.
12. Secure both venous and arterial cannulae in place by suturing them to the skin with nonabsorbable 2.0 silk sutures.
    NOTE: Central cannulation is routinely done in the operating room and typically requires sternotomy.
13. Perform direct cannulation of the right atrium and aorta after thoracotomy. Secure these in place using purse-string 4.0 prolene sutures, snuggers, and spigots.
14. Then, fix the cannulae to the chest wall from within the cavity using multiple sutures.
15. Leave the chest open with an occlusive dressing or closed at the conclusion. Tunnel the cannulae through the skin when the chest is closed.
16. Connect the cannulae (arterial and venous) to the ECMO circuit and increase the blood flow until respiratory and hemodynamic parameters are achieved.

3. Post initiation management

1. Patient monitoring
   1. Place a 7.5 Fr pulmonary artery catheter to aid clinical decision-making with periodic measurements of the pulmonary artery pressure and pulmonary capillary wedge pressure as a surrogate for left ventricular filling pressures.
      NOTE: This helps in identifying patients who are at risk of developing pulmonary edema, since VA-ECMO creates a right-to-left shunt by draining venous blood from the right atrium and returning oxygenated blood to the iliac arteries/descending aorta. While preload is reduced, an increase in afterload with VA-ECMO can increase the risk of pulmonary edema in patients with CS who already have an underlying LV dysfunction.
   2. Place the arterial lines in the right radial or left radial arteries using the micropuncture technique with the help of guidewire²⁷.
      NOTE: This helps determine the location of the watershed (area in the aortic arch where the antegrade flow from the left ventricle meets the retrograde flow from the arterial cannula)²⁸.
   3. Monitor the oxygen saturations from the right radial artery site to assess upper body (cerebral and right upper extremity) oxygenation. Perform arterial blood gas analysis every 8-12 h to ensure adequate oxygenation²⁹.
   4. Adjust FiO₂ on the oxygenator (dial up the knob) to maintain 60-100 mmHg PaO₂.
      NOTE: FiO₂ is usually set at 100% at the initiation of VA-ECMO and is subsequently titrated down as oxygenation improves.
   5. Optimize the ventilation and, thus, carbon dioxide removal by adjusting the sweep speed to between 3-7 L/min to correct for any respiratory acidosis.
   6. Serially monitor markers of end-organ perfusion such as lactate, SvO2, transaminases, and creatinine clearance by venous gas analysis^30,31.
      NOTE: Goal SvO₂ should be >70% and lactate less than 2.2 mmol/L.
2. Adjusting the flow and management of venous chatter
   1. Adjust the flow through the circuit to allow for adequate end-organ perfusion (target flow of 60 cc/kg/min). Change the flow by adjusting the speed of the pump. Maintain a flow of 4-6 L/min initially after cannulation.
      NOTE: Higher speeds of the pump, hypovolemia, and malpositioned venous cannula can lead to venous chatter, which manifests as suctioning or "chugging" of the venous cannula³². Venous chatter can lead to hemolysis by causing a vacuum in the pump head, as the rotor in the pump continues to spin and evacuate blood from the pump.
   2. Correct the venous chatter by fluid resuscitation in cases of hypovolemia. Reposition the venous cannula in case of malpositioning or kinking. Reduce the speed of the pump in case of high speed^33,34.
   3. Minimize the venous chatter by attaching a venous reservoir or a collapsible bladder to the inflow cannula. This allows to reduce suctioning of the inflow cannula by providing volume to the pump.
3. Left ventricular unloading
   NOTE: An increase in afterload from the retrograde VA-ECMO flow can lead to a higher LV end-diastolic pressure (LVEDP) and thus worsen pulmonary edema, and and severe cases of LV standstill may lead to thrombus formation from stagnated blood³⁵.
   1. To unload the LV and decrease afterload, utilize inotropes such as dobutamine (starting dose of 1-2 µg/kg/min) or vasodilators such as hydralazine or nitrates^36,37,38.
      NOTE: However, these are usually insufficient, and mechanical unloading of LV may be required.
   2. Place a ventricular support device (e.g., Impella) or intra-aortic balloon pump (IABP) percutaneously to accomplish direct unloading of the LV. To accomplish indirect unloading of the LV, place a pulmonary artery cannula percutaneously or perform balloon septostomy.
      NOTE: Surgical techniques, including transseptal left atrial drainage or direct cannulation of the LV apex, can also be employed for LV unloading³⁹.
4. Anticoagulation
   1. Initiate systemic anticoagulation at the time of cannulation. Use a bolus of 50-100 IU/kg of IV heparin (recommended) followed by continuous heparin as below.
   2. Continue unfractionated heparin to maintain an activated partial thromboplastin time or activated clotting time of at least 1.5 times the upper limit of normal during lab checks (every 4-6 h).
   3. In patients with heparin-induced thrombocytopenia, use direct thrombin inhibitors such as bivalirudin (starting dose of 0.025-0.05 mg/kg/h)⁴⁰ or argatroban (starting dose of 0.05-2 µg/kg/min)⁴¹ to reach therapeutic levels.

4. Prevention and management of complications

1. Harlequin (North-South) syndrome
   NOTE: Differential cyanosis of the upper body can occur when the watershed (the area where retrograde flow containing oxygenated blood from the outflow cannula meets antegrade blood the from LV) is distal to the origin of aortic arch branch vessels in the setting of concomitant respiratory failure. Deoxygenated blood from the LV supplies the upper body through the carotid and subclavian arteries, while the lower body is supplied by the blood from the outflow cannula of VA-ECMO. This phenomenon is called Harlequin syndrome or North-South syndrome (the upper body is blue, and the lower body is pink).
   1. Manage this differential cyanosis by increasing the oxygen saturation of blood returning to the LV by either increasing the FiO₂ or positive end-expiratory pressure if the patient is on mechanical ventilation or by returning oxygenated blood to the right atrium, typically through another cannula introduced in the internal jugular vein connected to the arterial limb of the ECMO circuit (V-A-V ECMO).
   2. Monitor the upper body oxygenation saturation every 8-12 h with arterial gas analysis (ABG) from the right radial artery. Adequate tissue oxygenation is ensured with 60-100 mmHg of PaO₂ on ABG⁴².
2. Lower limb ischemia
   NOTE: One of the most serious complications of peripheral arterial cannulation is antegrade ischemia in the lower extremity that rarely leads to compartment syndrome and, in extreme situations, may require amputation⁴³. The incidence of limb ischemia is variable, ranging from 10% to 70%, as reported by different studies⁴⁴.
   1. Choose an appropriate size cannula based on the diameter of the femoral arteries on the ultrasound, thus potentially decreasing lower limb ischemic complications.
   2. Monitor lower limb circulation following cannulation using serial pulse doppler or near-infrared spectroscopy (NIRS)⁴⁴. NIRS is a non-invasive imaging tool to access tissue oxygentaion⁴⁵.
   3. Perform continuous assessment of lower extremity tissue oxygenation using NIRS. Place the sensor pads on calf muscles connected to an oximeter to readily detect any change in tissue oxygenation, which is an indicator of perfusion.
   4. Insert an antegrade perfusion catheter (5-7 Fr) in the superficial femoral artery at the time of ECMO cannulation to prevent ischemic complications in the lower extremity.
3. Bleeding and hemolysis
   NOTE: A small degree of hemolysis is common after VA-ECMO initiation. Causes of significant hemolysis include pump thrombosis and clotting in the ECMO circuit.
   1. Carefully monitor for clinically significant hemolysis. Measure hemoglobin levels, lactate dehydrogenase, bilirubin, and creatinine daily.
   2. Consider interrupting systemic anticoagulation in patients with severe bleeding and thrombocytopenia⁴⁶. However, this may increase the risk of thrombotic complications; thus, careful assessment of bleeding and thrombotic risks should be done prior to holding anticoagulation.
4. Air embolism
   NOTE: Air entrapment in the ECMO circuit can occur from loose connections, peripheral or central venous access, or rupture of the oxygenator membrane⁴⁷. It can lead to air embolism, which can cause a stroke if air bubbles enter cerebral circulation.
   1. Lay the patient in the Trendelenburg position while on ventilatory support and clamp the ECMO circuit to manage air embolism
   2. De-air and re-prime the circuit when air embolism is suspected. Occasionally, the entire circuit may need replacement.

5. Weaning from ECMO

1. Assess the patients for weaning once they have recovered from the initial insult that prompted the use of VA-ECMO.
   NOTE: Concomitant respiratory failure must have been resolved prior to weaning.
2. Perform serial echocardiograms to assess for improvement in cardiac function and readiness for weaning.
3. Confirm hemodynamic stability prior to weaning a patient from VA-ECMO.
   NOTE: Patients must have recovered pulsatile arterial waveform for at least 24 h, and the mean arterial pressure should be >60 mmHg in the absence of or with low dose vasopressor use⁴⁸.
4. While weaning, perform an echocardiographic turndown study, where the ECMO flow is gradually decreased to a minimum of 1-1.5 L/min. Ensure hemodynamic stability and assess cardiac function on an echocardiogram.
   NOTE: Left ventricular (LV) ejection fraction of >20%-25%, aortic velocity-time integral of >10 cm, and lateral mitral annulus peak systolic velocity of >6 cm/s during the turndown study are predictors of successful weaning⁴⁹.
5. Monitor laboratory parameters of end-organ perfusion such as lactate, SvO2, and renal function while patients are being weaned.
6. To facilitate the weaning process, place a simplified weaning bridge⁵⁰ between the patient and the ECMO circuit prior to decannulation (this step is optional).
   NOTE: The weaning bridge allows patients to be observed off ECMO support and provides an opportunity to turn back on the ECMO circuit whenever required in a few minutes. It consists of a long tubing that connects inflow and outflow cannulae.
7. Place clamps on both inflow and outflow cannulae proximal to the weaning bridge, toward the patient side, thus separating the patient from the ECMO circuit and allowing blood to recirculate within the ECMO circuit.
8. After clamping the circuit, observe the patients for up to 24 h prior to decannulation. In case hemodynamic support is required, re-initiate ECMO flow by simply removing the tubing clamps.
9. To further augment weaning, use a ventricular support device (e.g., Impella) which can provide up to 5 L/min of flow. Increase the flow from the ventricular support device and turn down VA-ECMO flow systematically while ensuring hemodynamic stability.
   NOTE: One of the benefits of the ventricular support device is that it can be implanted using an axillary approach, thus allowing for early ambulation after the removal of VA-ECMO⁵¹.
10. Once the patient is deemed a candidate for removal of VA-ECMO, perform decannulation in the operating room or cardiac catheterization laboratory.
    NOTE: Most patients with peripheral arterial cannulation will require some degree of vascular repair.

Sonuçlar

Survival to hospital discharge after the use of VA-ECMO in refractory CS ranges from 28- 67%^{13,15,52,53,54,55,56}, as reported by various observational studies (Table 1). The outcomes vary based on the etiology of CS. In the ELSO registry, 9,025 adults were supported with ext...

Tartışmalar

In this protocol, various steps involved in the initiation and maintenance of VA-ECMO in patients with refractory CS are described. Some of the major complications, weaning parameters, and outcomes with the use of VA-ECMO have also been discussed.

VA-ECMO is usually employed as a rescue therapy when other management strategies fail to provide adequate hemodynamic support in CS. Cannulation involves large bore vascular access which should be performed meticulously to minimize vascular injury an...

Malzemeler

Name	Company	Catalog Number	Comments
Amplatz Super Stiff guidewire	Boston Scientific	46-500, 46-501, 46-502. 46-503, 46-504, 46-517, 46-519, 46-520, 46-523, 46-525, 46-526, 46-563, 46-564, 46-509, 46-510, 46-518, 46-524	Allows delivery of catheters across tortuous anatomies
Impella	Abiomed	Impella 2.5, Impella CP, Impella 5.0, Impella 5.5, Impella RP	Percutaneously inserted left ventricular assist device that provides hemodynamic support in cardiogenic shock
Inflow Cannula	Surge Cardiovascular	FEM-V1020, FEM-V1022, FEM-V1024, FEM-V1026,FEM-V1028	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	Biomedicus 96600-019,021,023,025,027,029	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	Biomedicus Femoral Venous 96670 - 017,019, 021, 023	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	Biomedicus Multi-Stage Femoral Venous 96880-019,021,025	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	Biomedicus NextGen 96600 - 115, 117, 119, 121, 123, 125, 127, 129	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	Carmeda Biomedicus CB96605-015,017,019,021,023,025,29	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	Cortiva Biomedicus Femoral Venous CB96670-015,017,019,021	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	DLP Carmeda Venous CB75008, CB66112, CB66114, CB66116, CB66118, CB66120, CB66122,CB66124	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Getinge	Avalon Elite Bicaval - 10013, 10016, 10019, 10020, 10023, 10027, 10031	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Getinge	HLS Cannula Venous Bioline - BE PVS 1938, 2138, 2155, 2338, 2355, 2538, 2555, 2955	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Getinge	HLS Cannula Venous Softline - BO PVS 1938, 2138, 2155, 2338, 2355, 2538, 2555, 2955	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Getinge	HLS Cannula Venous - PVS 1938, 2138, 2155, 2338, 2355, 2538, 2555, 2955	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	Life Support Bio-Medicus Drainage Catheter and Introducers - LS96218 - 015, 017, 019, 021, 023, 025 ; LS96438 - 021, 023, 025, LS 96555 - 019, 021, 023, 025, LS 96355 - 021, LS96360 -023, 025, 027, 029	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Fresenius	Medos Femoral Cannula MEFKV 18,20,22,24,26,28	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Medtronic Cardiopulmonary	Medtronic 2 stage venous - 91228, 91240, 91246, 91236,91251	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Senko/Mera	PCKC-V-24, PCKC-V2-18, PCKC-V-18, PCKC-V2-20, PCKC-V-20, PCKC-V-22, PCKC-V2-24, PCKC-V-24	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	TandemLife/Livanova	29,31 Fr	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Freelife Medical	FLK V19 B18, FLK V19 B18R, FLK VV 19R, FLK V20 B20, FLK V20 B20R, FLK V19 B20, FLK V19 B20R, FLK V20 B22, FLK V20 B22R, FLK V10S B22, FLK V19 B22, FLK V19 B22R, FLK V10 B22, FLK V10 B22R, FLK V10S B22R, FLK VV 23R, FLK V10S B24, FLK V10S B24R, FLK V10 B24, FLK V10 B24R, FLK V10S B26, FLK V10S B26R, FLK V10 B26, FLK V10 B26R, FLK VV 27R, FLK VV 31R	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	LivaNova	Sorin right angle venous - 10, 12, 14, 16, 18, 20, 22, 24, 28	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Inflow Cannula	Terumo	CX-EB18VLX, CX-EB21VLX	Removes deoxygenated blood from the central venous circulation into the ECMO circuit
Outflow Cannula	Medtronic Cardiopulmonary	Biomedicus Arterial 96530 - 015,017, 019, 021, 023, 025,	Returns oxygenated blood to the body
Outflow Cannula	Medtronic Cardiopulmonary	Biomedicus Femoral Arterial 96570 - 015, 017, 019, 021	Returns oxygenated blood to the body
Outflow Cannula	Medtronic Cardiopulmonary	Biomedicus NextGen Arterial 96530 -115, 117, 119, 121, 123, 125, 96570 - 115, 117, 119, 121	Returns oxygenated blood to the body
Outflow Cannula	Medtronic Cardiopulmonary	Carmeda Biomedicus CB96535 - 015, 017, 019, 021, 023	Returns oxygenated blood to the body
Outflow Cannula	Medtronic Cardiopulmonary	Cortiva Biomedicus Femoral Arterial CB96570 -015, 017, 019, 021	Returns oxygenated blood to the body
Outflow Cannula	Getinge	PAS 1315, PAS 1515, PAS 1523, PAS 1717, PAL 1723, PAL 1923, PAL 2115, PAL 2123, PAL 2315, PAL 2323	Returns oxygenated blood to the body
Outflow Cannula	Getinge	Bioline BE PAS 1315, BE PAS 1515, BE PAL 1523, BE PAL 1723, BE PAS 1915, BE PAL 1923, BE PAS 2115, BE PAL 2123, BE PAS 2315, BE PAL 2323,	Returns oxygenated blood to the body
Outflow Cannula	Getinge	Softline BO PAS 1315, BO PAS 1515, BO PAL 1523, BO PAS 1715, BO PAL 1723, BO PAS 1915, BO PAL 1923, BO PAS 2115, BO PAL 2123, BO PAL 2323	Returns oxygenated blood to the body
Outflow Cannula	Fresenius	Medos Femoral Arterial Cannula; MEFKA 16, 18, 20, 22,24	Returns oxygenated blood to the body
Outflow Cannula	Senko/Mera	PCKC-A-20, PCKC-A-16, PCKC-A-18	Returns oxygenated blood to the body
Outflow Cannula	Freelife Medical	FLK A18 D16, FLK A18L D16, FLK A18L D16R, FLK A18 D16R, FLK A44 D18, FLK A44 D18R, FLK A18 D18, FLK A18L D18, FLK A18L D18R, FLK A18 D18R, FLK A44 D20, FLK A44 D20R, FLK A18 D20, FLK A18L D20, FLK A18L D20R, FLK A18 D20R, FLK A18 D22, FLK A18L D22, FLK A18L D22R, FLK A18 D24, FLK A18L D24, FLK A18L D24R, FLK A18 D24R	Returns oxygenated blood to the body
Outflow Cannula	LivaNova	Sorin arterial - 14, 17, 19, 21, 23 Fr	Returns oxygenated blood to the body
Outlflow Cannula	Medtronic Cardiopulmonary	Life Support Bio-Medicus Return Catheter and Introducers - LS96010-009, LS96010-011, LS96010-013, LS96010-015, LS96218-015, LS96218-017, LS96218-019, LS96218-021, LS96218-023, LS96218-025	Returns oxygenated blood to the body
Oxygenator	Abbott	Eurosets	Deoxygenated blood from the inflow cannula is saturated with oxygen
Oxygenator	Getinge	MaquetHLS Set Advanced v 5.0, v 7.0, Maquet Quadrox iD	Deoxygenated blood from the inflow cannula is saturated with oxygen
Oxygenator	Medtronic	Nautilus	Deoxygenated blood from the inflow cannula is saturated with oxygen
Pump	Abiomed	Breethe	Generates force to deliver oxygenated blood back to the body
Pump	LivaNova	Alcard ALC 250	Generates force to deliver oxygenated blood back to the body
Pump	Baxter	Century Roller Pump	Generates force to deliver oxygenated blood back to the body
Pump	Medtronic Cardiopulmonary	Biomedicus BP50, BP80 Centrifugal	Generates force to deliver oxygenated blood back to the body
Pump	Braile Biomedica	Safyre	Generates force to deliver oxygenated blood back to the body
Pump	Getinge	CiSet	Generates force to deliver oxygenated blood back to the body
Pump	Abbott	CentriMag	Generates force to deliver oxygenated blood back to the body
Pump	LivaNova	Cobe 6" Roller	Generates force to deliver oxygenated blood back to the body
Pump	Origen	FloPump 32	Generates force to deliver oxygenated blood back to the body
Pump	Getinge	HIT Set Advanced Softline 5.0 and 7.0	Generates force to deliver oxygenated blood back to the body
Pump	LivaNova	LifeSPARC	Generates force to deliver oxygenated blood back to the body
Pump	Senko/Mera	Centrifugal pump head	Generates force to deliver oxygenated blood back to the body
Pump	Getinge	HLS Set Advanced Bioline 5.0 and 7.0	Generates force to deliver oxygenated blood back to the body
Tandem Heart	LivaNova	Tandem Heart LS	Percutaneously inserted left ventricular assist device