**3. Conclusions**

reported that more than half of the patients required re-exploration of the chest for bleeding

Cerebrovascular events also occurred frequently. Smedira et al. reported that 33% of the patients developed neurologic events [30], and Rastan et al. reported that the incidence of cerebrovascular events was 17.4% [24]. The reasons for high incidence of cerebrovascular events include the operative procedure itself, hemodynamic instability, lack of pulsatile flow,

Leg ischemia is a complication specifically associated with peripheral ECMO institution [44]. Rastan et al. reported that about 20% of the patients developed leg ischemia and 9.2% required leg fasciotomy [24]. However, the risk of this complication can be reduced by using a distal leg perfusion cannula [24], or by using a dacron or hemashield prosthetic graft sewn onto the artery to maintain both central arterial blood flow as well as distal limb

A meta-analysis performed by Biancari et al. reported that the rate of reoperation for bleeding was 42.9%, major neurological event 11.3%, lower limb ischemia 10.8%, deep sternal wound

When patients have difficulty of being weaned from ECMO, physicians need to consider if they have to withdraw ECMO from them, or if they proceed to alternative options. Patients were more likely to be considered for bridging to heart transplantation if they are less than 60 years of age. Smedira et al. reported that 24% were bridged to heart transplantation [30].

Other options include left ventricular assist device (LVAD) or right ventricular assist device (RVAD). Muehrcke et al. reported that 4 out of 23 patients were transferred to an implantable LVAD from ECMO [25]. Pokersnik et al. reported that 2 out of 49 patients were bridged to

Post-cardiotomy shock may happen at institutions which do not have much experience with the management of mechanical circulatory support devices. In addition, not all institutions have options of long-term devices such as LVAD, or transplantation. Therefore, the development of a robust program of tertiary referral is of paramount importance [45]. Javidfar et al. reported no transport-related mortality or morbidity in patients who were transported via an

Teman et al. reported that patients with post-cardiotomy cardiac shock transported to a ter-

Weaning to recovery, institution of long-term support as a bridge to recovery, transition to transplantation or destination therapy, as well as device withdrawal and palliative care should be discussed in a multidisciplinary team including cardiologists, surgeons, intensiv-

[24]. Golding et al. reported that 87.3% required re-exploration for bleeding [43].

retrograde perfusion via peripheral circuit, and anticoagulation-related injuries.

infection 14.7%, and renal replacement therapy 47.1% [41].

long-term devices—bi-ventricular assist devices [39].

tiary care center had a nearly 50% survival [47].

ists, psychiatrists, and social workers [21].

However, heart transplantation is not an available option in all countries.

perfusion [32].

**2.8. Bridge to alternatives**

112 Advances in Extra-corporeal Perfusion Therapies

**2.9. Hospital transfer**

ambulance with ECMO [46].

The surgical mortality after ECMO use for post-cardiotomy cardiogenic shock remains high despite technological advancement. However, ECMO is the last resort to keep a patient alive who would otherwise expire on the operating table. According to the literatures, ECMO can be a salvage treatment in about one-third of these patients. Increased age, chronic kidney disease, and high level of lactate are major risk factors associated with hospital mortality. Also longer duration of ECMO support is associated with poor outcome. There is no guideline regarding optimal patient selection, duration of mechanical support, and management of ECMO.

A careful decision-making is necessary before ECMO is initiated, because ECMO is associated with a significant burden to a facility. As patients who need ECMO are always heterogeneous, the decision should be based on an individual basis.

A transfer to a tertiary center is critically important, because they can provide the transition to further supports, such as heart transplantation and implantable ventricular assist devices for patients who have difficulty of being weaned from ECMO.
