**7. Conclusions**

Today, the first indication of treatment is weaning from ECMO and myocardial recovery. This target is more frequently achieved in myocarditis or potentially reversible diseases and stresses the importance of etiological diagnosis at the moment of implantation to define the strategy of implantation. In **Figure 11** there is a flow chart that clarifies how VA-ECMO should be managed, according to the etiology, to reach the weaning from ECMO goal and myocardial recovery, analysing the phases of the hemodynamic support and detecting unloading need at the right time.

**Figure 11.** Flow chart on VA-ECMO management according to etiology.

VA-ECMO has to be deemed as temporary short-term support, and the risks related to the permanence of an oxygenator must focus on a rapid transition to further MCS systems. The assessment of left atrial pressure (direct or indirect) should be a mandatory tool in patients with VA-ECMO to increase the chance of recovery or transition to next support or treatment. When left atrial pressure is deemed increased in surgical unloading, or percutaneous unloading has to be considered preferring whenever possible ventricular unloading especially when mitral regurgitation is absent.

Randomized trials and registries will have to answer some of the open questions the clinician has to solve daily, dealing with the patient on VA-ECMO:


ventricle. A recent study from Sakir Akin and the Erasmus group has shown how the peripheral recovery of pulsatility is a predictor of recovery that should push to weaning of ECMO [84].

Reduced pulsatility may also reflect a decrease in intravascular volume or a mechanical cause of decreased venous return (i.e., atrial tamponade) that may cause a decrease in LV preload

VA-ECMO reduces the volume work of the right ventricle through the decreased RV preload, while pulmonary edema may cause hypoxic pulmonary vasoconstriction worsening pulmonary hypertension and increasing RV pressure work. If this setting, the right ventricle may be unable to pump to the left side of the heart, flattening arterial pressure waveform and decreasing the stroke volume. Nitric oxide with inodilators such as milrinone and dobutamine (which will also provide inotropic assistance) are needed. If systemic pressures allow,

Today, the first indication of treatment is weaning from ECMO and myocardial recovery. This target is more frequently achieved in myocarditis or potentially reversible diseases and stresses the importance of etiological diagnosis at the moment of implantation to define the strategy of implantation. In **Figure 11** there is a flow chart that clarifies how VA-ECMO should be managed, according to the etiology, to reach the weaning from ECMO goal and myocardial recovery, analysing the phases of the hemodynamic support and detecting unloading need

leading decreased stroke volume and pulse pressure.

202 Advances in Extra-corporeal Perfusion Therapies

nitroglycerin or nitroprusside may also be utilized.

**Figure 11.** Flow chart on VA-ECMO management according to etiology.

**7. Conclusions**

at the right time.

