**2. Conclusions**

It cannot be emphasized enough that a key component to a successful program is appropriate patient selection. Despite all of the advances in ECMO therapies over the years, even successful programs have outcomes that range from 60 to 70% survival for veno-veno pulmonary support and 25–35% for veno-arterial cardiopulmonary and emergent cardiopulmonary resuscitation applications (E-CPR) [9, 10]. Lower success rates that improve over time and with experience, improvements in institutional protocols, and better (and more-timely) patient selection can be expected during the early phases of program development. Alternatively, as is seen with other areas of innovative clinical therapies, programmatic successes and improving outcomes spur attempts at treating higher-risk patients, resulting in a paradoxical loss in these successes. Programs with inordinately high success rates may be depriving salvageable patients the opportunity for survival because their indications are slightly out of the boundaries of the traditional indications for therapy. Programmatic attempts to support lower-risk patients on ECMO are not uncommon and are typically based on institutional (and personal) biases and outcomes. A series of successes with low-risk patients then rationalizes attempts to salvage the higher-risk patient. Conversely, lower than desired outcomes in higher-risk patients might then limit selection back to patients with low-risk characteristics. Regardless, institutional checks and balances as well as systems for reviewing metrics (clinical and financial) and outcomes should be established. Team engagement at all levels—from bedside nursing to top administrative leadership—is critical and cannot be emphasized enough. Membership and participation in the Extra-Corporeal Life Support Organization (ELSO: https://www.elso.org) should be encouraged, as it can provide data to help benchmark institutional success. Membership can also provide a community in which to partner with colleagues, exchange

4 Advances in Extra-corporeal Perfusion Therapies

ideas, and as a resource for timely and important developments in the field.

Unusual patient populations represent one of the most rapidly expanding populations for ECMO. For example, early experiences with ECMO to support overwhelming septic shock in the setting of necrotizing soft tissues infections and the long-term, albeit anecdotal, good outcomes in this clinical scenario have prompted greater enthusiasm for otherwise potentially "hopeless" cases [11, 12]. There is also growing evidence supporting the role of ECMO to support high-risk catheter-based interventions, as discussed in the chapter by Dr. Ganyukov and colleagues [13]. However, such applications are limited to high-risk procedures in the catheterization laboratory, defined as those with impaired ventricular function and complex anatomy, or to reduce the risk of inherently high-risk or complex interventions, such as percutaneous aortic valve procedures (i.e., transcatheter aortic valve replacement), coronary or cardiac structural interventions, or electrophysiologic ablative procedures for complex arrhythmias. The key goal of providing ECMO support during these procedures is to reduce the risks of end-organ dysfunction. Hemodynamic instability (or even acute failure) during such procedures could be reduced by using ECMO to provide support for brief periods of time until the pathology is corrected (i.e., the coronary artery is stented or valve dilated) [14]. Managing patients on ECMO represents one of the greatest clinical challenges in all of medicine. Management on ECMO can be divided into several areas, and management decisions must be made in the context of the complex limitations of caring for patients on ECMO. For example, in many areas, there are little, if any, randomized evidence, established protocols, or even well-developed guidelines. Even simple interventions, like transporting patients on ECMO, require team-based decision-making regarding the potential risks and benefits [15]. The goal of this text is to demonstrate further that ECMO continues to evolve as a mainstream therapy for patients experiencing acute, severe, medically refractory cardiac and/or pulmonary

**Figure 2.** BH (center in wheelchair) with his parents after qualifying for the finals in the single-scull, arms and shoulder only, rowing competition in the 2016 Paralympics in Rio de Janeiro. BH, a five-time USA national champion in the event, represented the USA in Rio as a member of the Olympic team. In 2016 he was elected US Rowing "Rower of the Year". Several years prior, BH lost both legs to complications of a necrotizing soft tissue infection and required cardiopulmonary support with veno-arterial ECMO due to overwhelming septic shock. Picture used by permission by all represented [11, 12].

failure. Contemporary trials continue to define the role of ECMO as the search for better outcomes evolve [16]. However, as technology improves, guidelines get developed, protocols get refined, and experience grows, without a doubt, outcomes will improve [17]. ECMO, as a function of its invasiveness, need for substantial resources, and high-risk/high-reward, and novel technologies (i.e., the pump and oxygenators) often generates much institutional interest and intrigue. Unfortunately, many patients, despite such heroic efforts, die on ECMO—even when everything appears to have been done "right." As important as it is to learn from all outcomes, it is critical that everyone cherishes all victories. Victories can inspire, give hope, and motivate a team even when further treatments appear futile (**Figure 2**). Even though there is still much to learn on the topic of ECMO, the goal of this text is to continue to build on the growing foundation of experiences and the current literature. If nothing else, the hope is to help inspire those intrigued by and who believe in the potential benefits of ECMO [18].

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