Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

ECMO in cardiogenic shock and bridge to heart transplant



The aim of this review is to discuss the role of extracorporeal membrane oxygenation (ECMO) in cardiogenic shock and its use to bridge patients to heart transplantation.

Methods and results

Consideration of published literature reveals indications for ECMO in cardiogenic shock and tools for patient selection, adequate evidence of its efficacy, its advantages when compared with other temporary mechanical circulatory support devices and details of its use as a bridge to decision, bridge to recovery, bridge to bridge (durable ventricular assist device) and bridge to heart transplant.


ECMO is invaluable in treating patients with medically refractory profound cardiogenic shock and allows for cardiac recovery or planning for permanent heart replacement treatments.

This is a preview of subscription content, log in to check access.


  1. 1.

    Harjola VP, Lassus J, Sionis A, et al. Clinical picture and risk prediction of short-term mortality in cardiogenic shock. Eur J Heart Fail. 2015;17:501–9.

  2. 2.

    van Diepen S, Katz JN, Albert NM, et al. Contemporary management of cardiogenic shock. A scientific statement from the American Heart Association. Circulation. 2017;136:e232–68.

  3. 3.

    Baran DA, Grines CL, Bailey S, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock. Catheter Cardiovasc Interv. 2019;94:29–37.

  4. 4.

    Poss J, Köster J, Fuernau G, et al. Risk stratification for patients in cardiogenic shock after acute myocardial infarction. J Am Coll Card. 2017;69:1913–20.

  5. 5.

    ELSO Guidelines General v1.4. General Guidelines for all ECLS Cases. ELSO Guidelines for Cardiopulmonary Extracorporeal Life Support. Extracorporeal Life Support Organization,Version 1.4 August 2017., accessed on 8 October 2019.

  6. 6.

    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;36:2246–56.

  7. 7.

    Muller G, Flecher E, Lebreton G, et al. The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock. Intensive Care Med 2016; 42:370–378.

  8. 8.

    Ouweneel DM, Schotborgh JV, Limpens J, et al. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016;42:1922–34.

  9. 9.

    Nichol G, Karmy-Jones R, Salerno C, Cantore L, Becker L. Systematic review of percutaneous cardiopulmonary bypass for cardiac arrest or cardiogenic shock states. Resuscitation. 2006;70:381–94.

  10. 10.

    Extracorporeal membrane oxygenation (ECMO) for acute heart failure in adults. Interventional procedures guidance [IPG482] Published date: March 2014. National Institute for health and Care Excellence (NICE).

  11. 11.

    ECLS registry report, international summary, July 2019.

  12. 12.

    Thiele H, Zeymer U, Neumann FJ, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. New Engl J Med. 2012;367:1287–96.

  13. 13.

    Ouweneel DM, Eriksen E, Seyfarth M, Henriques JP. Percutaneous mechanical circulatory support versus intra-aortic balloon pump for treating cardiogenic shock: meta-analysis. J Am Coll Cardiol. 2017;69:358–60.

  14. 14.

    Cheng JM, den Uil CA, Hoeks SE, et al. Percutaneous left ventricular assist devices vs. intra-aortic balloon pump counterpulsation for treatment of cardiogenic shock: a meta-analysis of controlled trials. Eur Heart J. 2009;30:2102–8.

  15. 15.

    Smith M, Vukomanovic A, Brodie D, Thiagarajan R, Rycus P, Buscher H. Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the extracorporeal life support organization (ELSO) registry. Crit Care. 2017;21:45.

  16. 16.

    Kara A, Akin S, dos Reis Miranda D, et al. Microcirculatory assessment of patients under VA-ECMO. Crit Care.2016; 20:344.

  17. 17.

    den Uil CA, Lagrand WK, van der Ent M, et al. Conventional hemodynamic resuscitation may fail to optimize tissue perfusion: an observational study on the effects of dobutamine, enoximone, and norepinephrine in patients with acute myocardial infarction complicated by cardiogenic shock. PLoS One. 2014;9:e103978.

  18. 18.

    Sheu JJ, Tsai TH, Lee FY, et al. Early extracorporeal membrane oxygenator–assisted primary percutaneous coronary intervention improved 30-day clinical outcomes in patients with ST-segment elevation myocardial infarction complicated with profound cardiogenic shock. Crit Care Med. 2010;38:1810–7.

  19. 19.

    Cheng R, Hachamovitch R, Kittleson M, et al. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Ann Thorac Surg. 2014;97:610–6.

  20. 20.

    Aubron C, DePuydt J, Belon F, et al. Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation. Ann Intensive Care. 2016;6:97.

  21. 21.

    Takayama H, Landes E, Truby L, et al. Feasibility of smaller arterial cannulas in venoarterial extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg. 2015;149:1428–33.

  22. 22.

    Migdady I, Rice C, Uchino K, Cho S. Neurological outcomes of extracorporeal cardiopulmonary resuscitation (ECPR): a systematic review. Neurology.

  23. 23.

    Le Guennec L, Cholet C, Huang F, et al. Ischemic and hemorrhagic brain injury during venoarterial-extracorporeal membrane oxygenation. Ann Intensive Care. 2018;8:129.

  24. 24.

    Fletcher Sandersjöö A, Bartek J, Theline EP, et al. Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study. J Intensive Care. 2017;5:27.

  25. 25.

    Kasirajan V, Smedira NG, McCarthy JF, Casselman F, Boparai N, McCarthy PM. Risk factors for intracranial hemorrhage in adults on extracorporeal membrane oxygenation. Eur J Cardiothorac Surg. 1999;15:508–14.

  26. 26.

    Suarez L, Iafrati M. PC054 the impact of cannula-related limb ischemia on ECMO patient survival. J Vasc Surg. 2017;65:154S.

  27. 27.

    Juo YY, Skancke M, Sanaiha Y, Mantha A, Jimenez JC, Benharash P. Efficacy of distal perfusion cannulae in preventing limb ischemia during extracorporeal membrane oxygenation: a systematic review and meta-analysis. Artif Organs. 2017;41:E263–73.

  28. 28.

    Abrams DC, Prager K, Blinderman CD, Burkart KM, Brodie D. Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults. Chest. 2014;145:876–82.

  29. 29.

    Carter T, Bodzin AS, Hirose H, et al. Outcome of organs procured from donors on extracorporeal membrane oxygenation support: an analysis of kidney and liver allograft data. Clin Transpl. 2014;28:816–20.

  30. 30.

    Tarzia V, Bortolussi G, Bianco R, et al. Extracorporeal life support in cardiogenic shock: impact of acute versus chronic etiology on outcome. J Thorac Cardiovasc Surg. 2015;150:333–40.

  31. 31.

    Marasco SF, Vale M, Pellegrino V, et al. Extracorporeal membrane oxygenation in primary graft failure after heart transplantation. Ann Thorac Surg. 2010;90:1541–6.

  32. 32.

    Chinnadurai T, Patel SR, Sims D, et al. Primary graft failure is more common in patients bridged to heart transplant with LVAD: role of early peripheral ECMO. J Heart Lung Transplant. 2018;37:S349.

  33. 33.

    Phan K, Luc JGY, Xu J, et al. Utilization and outcomes of temporary mechanical circulatory support for graft dysfunction after heart transplantation. ASAIO J. 2017;63:695–703.

  34. 34.

    Takeda K, Li B, Garan AR, et al. Improved outcomes from extracorporeal membrane oxygenation versus ventricular assist device temporary support of primary graft dysfunction in heart transplant. J Heart Lung Transplant. 2017;36:650–6.

  35. 35.

    D'Alessandro C, Aubert S, Golmard JL, et al. Extra-corporeal membrane oxygenation temporary support for early graft failure after cardiac transplantation. Eur J Cardiothorac Surg. 2010;37:343–9.

  36. 36.

    Lorusso R, Centofanti P, Gelsomino S, et al. Venoarterial extracorporeal membrane oxygenation for acute fulminant myocarditis in adult patients: a 5-year multi-institutional experience. Ann Thorac Surg. 2016;101:919–26.

  37. 37.

    Cheng R, Hachamovitch R, Kittleson M, et al. Clinical outcomes in fulminant myocarditis requiring extracorporeal membrane oxygenation: a weighted meta-analysis of 170 patients. J Card Fail. 2014;20:400–6.

  38. 38.

    Hsu KH, Chi NH, Yu HY, et al. Extracorporeal membranous oxygenation support for acute fulminant myocarditis: analysis of a single center's experience. Eur J Cardiothorac Surg. 2011;40:682–8.

  39. 39.

    Diddle JW, Almodovar MC, Rajagopal SK, Rycus PT, Thiagarajan RR. Extracorporeal membrane oxygenation for the support of adults with acute myocarditis. Crit Care Med. 2015;43:1016–25.

  40. 40.

    den Uil CA, Akin S, Jewbali LS, et al. Short-term mechanical circulatory support as a bridge to durable left ventricular assist device implantation in refractory cardiogenic shock: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2017;52:14–25.

  41. 41.

    Sakamoto S, Taniguchi N, Nakajima S, Takahashi A. Extracorporeal life support for cardiogenic shock or cardiac arrest due to acute coronary syndrome. Ann Thorac Surg. 2012;94:1–7.

  42. 42.

    Garan AR, Eckhardt C, Takeda K, et al. Predictors of survival and ability to wean from short-term mechanical circulatory support device following acute myocardial infarction complicated by cardiogenic shock. Eur Heart J Acute Cardiovasc Care. 2018;7:755–65.

  43. 43.

    Khorsandi M, Dougherty S, Bouamra O, et al. Extra-corporeal membrane oxygenation for refractory cardiogenic shock after adult cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Surg. 2017;12:55.

  44. 44.

    Wang L, Yang F, Wang X, et al. Predicting mortality in patients undergoing VA-ECMO after coronary artery bypass grafting: the REMEMBER score. Crit Care. 2019;23:11.

  45. 45.

    Truby LK, Takeda K, Mauro C, et al. Incidence and implications of left ventricular distention during venoarterial extracorporeal membrane oxygenation support. ASAIO J. 2017;63:257–65.

  46. 46.

    Pappalardo F, Schulte C, Pieri M, et al. Concomitant implantation of Impella(R) on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock. Eur J Heart Fail. 2017;19:404–12.

  47. 47.

    Aso S, Matsui H, Fushimi K, Yasunaga H. The effect of intraaortic balloon pumping under venoarterial extracorporeal membrane oxygenation on mortality of cardiogenic patients: an analysis using a nationwide inpatient database. Crit Care Med. 2016;44:1974–9.

  48. 48.

    Aissaoui N, Luyt CE, Leprince P, et al. Predictors of successful extracorporeal membrane oxygenation (ECMO) weaning after assistance for refractory cardiogenic shock. Intensive Care Med. 2011;37:1738–45.

  49. 49.

    Chang WW, Tsai FC, Tsai TY, et al. Predictors of mortality in patients successfully weaned from extracorporeal membrane oxygenation. PLoS One. 2012;7:e42687.

  50. 50.

    Kirklin JK, Naftel DC, Kormos RL, et al. Fifth INTERMACS annual report: risk factor analysis from more than 6,000 mechanical circulatory support patients. J Heart Lung Transplant. 2013;32:141–56.

  51. 51.

    Potapov EV, Antonides C, Crespo-Leiro MG, et al. 2019 EACTS expert consensus on long-term mechanical circulatory support. Eur J Cardiothorac Surg. 2019;56:230–70.

  52. 52.

    Shah P, Pagani FD, Desai SS, et al. Outcomes of patients receiving temporary circulatory support before durable ventricular assist device. Ann Thorac Surg. 2017;103:106–12.

  53. 53.

    Garan AR, Malick WA, Habal M, et al. Predictors of survival for patients with acute decompensated heart failure requiring extra-corporeal membrane oxygenation therapy. ASAIO J. 2019;65:781–7.

  54. 54.

    Colvin M, Smith JM, Hadley N, et al. OPTN/SRTR 2017 annual data report: heart. Am J Transplant. 2019;19:323–403.

  55. 55.

    Adult heart allocation—Organ Procurement and Transplantation Network. 2018. Available from: on 8 October 2019.

  56. 56.

    Zalawadiya S, Fudim M, Bhat G, Cotts W, Lindenfeld J. Extracorporeal membrane oxygenation support and post-heart transplant outcomes among United States adults. J Heart Lung Transplant. 2017;36:77–81.

  57. 57.

    Fukuhara S, Takeda K, Kurlansky PA, Naka Y, Takayama H. Extracorporeal membrane oxygenation as a direct bridge to heart transplantation in adults. J Thorac Cardiovasc Surg. 2018;155:1607–18.

  58. 58.

    Barge-Caballero E, Almenar-Bonet L, Gonzalez-Vilchez F, et al. Clinical outcomes of temporary mechanical circulatory support as a direct bridge to heart transplantation: a nationwide Spanish registry. Eur J Heart Fail. 2018;20:178–86.

  59. 59.

    Takeda K, Garan AR, Topkara VK, et al. Novel minimally invasive surgical approach using an external ventricular assist device and extracorporeal membrane oxygenation in refractory cardiogenic shock. Eur J Cardiothorac Surg. 2017;51:591–6.

Download references


No funding was received by the authors for the research, authorship and /or publication of this article.

Author information

Correspondence to Mathew Jose Chakaramakkil.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical statements and Human and Animal Rights Consent

Not applicable being a review article.

Informed consent

Not applicable being a review article.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Chakaramakkil, M.J., Sivathasan, C. ECMO in cardiogenic shock and bridge to heart transplant. Indian J Thorac Cardiovasc Surg (2020).

Download citation


  • ECMO
  • Mechanical circulatory support
  • Cardiogenic shock
  • Heart transplant