**4. Indication and contraindications for v-a ECMO**

Patient selection is a crucial point when the physician needs to take the decision to institute ECMO and several considerations must be focused up. Most importantly, it must be consider the likelihood of heart and end organs recovery. If the organs failure is thought to be reversible with ECMO, in such situation the device application is to be encouraged. If the likelihood of recovery of the heart or other end organs is thought to be very low or even impossible, then other factors must be taken into account. In such clinical scenario, the decision to institute ECMO should be based on an experienced ECMO team approach, which has to evaluate the patient's eligibility for heart transplantation or a definitive mechanical assist device (LVAD) implant as destination therapy.

**5.2. ECMO cannulas and cannulation techniques**

**Figure 2.** Peripheral cannulation for V-A ECMO.

bleeding, infections, and mediastinitis.

**Figure 3.** Central cannulation for V-A ECMO

Cannulation is one of the most challenging aspects of ECMO. Peripheral percutaneous approach [6, 21 is the most used in cardiogenic shock and cardiac arrest [7, 22] because is

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The open surgical approach is considered for patients with severe peripheral vascular disease or for patients with postcardiotomy syndrome or failure of weaning from cardiopulmonary bypass [23, 24] (Figure 3). The open or central cannulation has more complications such as

quicker with less bleeding complications and easier decannulation. (Figure 2).

#### **4.1. Indications for v-a ECMO**

The following factors need to be evaluated for the indications [19]:


#### **4.2. Contraindications for v-a ECMO**

Contraindications to the institution of v-a ECMO include [20]:

