**6. Conclusions**

The use of VA-ECMO as a technique for rescuing patients from cardiogenic shock is very attractive. However, considering the extensive set of complications and the mortality it brings with it makes it a less attractive option as a direct bridge to cardiac transplant. The literature currently on this subject is very scanty and limited to a few studies of small numbers of patients. The existing literature from France suggests a higher rate of posttransplant deaths even though the wait list mortality was reduced which does not seem to be an optimal way for organ allocation. In the light of present findings, further definitive research is needed for a consensus on the role of VA-ECMO as a bridge to cardiac transplant.

*Advances in Extracorporeal Membrane Oxygenation - Volume 3*

that needs future attention.

guidelines.

products.

**4.4 Heparin-induced thrombocytopenia**

**4.5 Disseminated intravascular coagulation**

**5. ECMO as a bridge to transplantation**

without direct SFA pressure measurements especially if it can be done at the bedside. Duplex ultrasonography or direct SFA pressure measurements done at the time of ECMO placement may be an alternative to an early decision on which patients need the SFA cannulation. The existing literature does not seem to report a direct correlation with mortality in these patients which is another area of investigation

Thrombocytopenia is a devastating complication in patients on VA-ECMO support. The etiology of platelet reduction in ECMO is still ambiguous. HIT has been considered one of the causative mechanisms. Current literature has very little to offer in this area. The incidence and mortality secondary to HIT in VA-ECMO patients is very poorly represented. In a recent retrospective study on VA-ECMO patients hospitalized for >3 days with high clinical suspicion of HIT and positive anti-PF4/heparin antibodies, the prevalence of HIT in patients on VA-ECMO support was estimated as 0.36%. Mortality rate was noted as 33.3%, which was not statistically different from the mortality observed in patients on VA-ECMO support without HIT [26]. HIT is a complication that appears to have a low prevalence; its effects are devastating if untreated. Bivalirudin and argatroban have been used to successfully treat this condition in VA-ECMO patients in small studies [27–29]. Further investigations in larger populations are required in this patient population for standardized regimens to be incorporated into the

Extracorporeal cardiopulmonary resuscitation (eCPR) with VA-ECMO has become a reality in today's medicine to rescue patients in refractory cardiac arrest. DIC therefore becomes an important issue in this subset of patients who experience serious abnormalities in coagulation and thrombosis. Survival of adults supported by eCPR in adults is lower than that noted in patients supported on VA-ECMO [30]. In a retrospective analysis of eCPR patients it was noted they had consistently higher DIC scores and the mean DIC scores was significantly different between survivors and non-survivors [31]. It may be reasonable to use DIC scores in prognostication in these patients. Further studies are warranted in this area. Such prognostication remains very important as it can curtail excessive use of blood

Cardiac transplant still remains the gold standard in treatment of end-stage heart failure. The scarcity of donors has led to the generation of a whole field of mechanical circulatory support devices which has brought in a new era in the treatment of advanced heart failure. The use of continuous flow LVADs as a bridge to transplantation (BTT) has become more popular and the mainstay of patients waiting on the transplant list [32]. More recently, VA-ECMO is being increasingly used as a rescue therapy [33, 34] However, this trend has now led to the use of ECMO as a direct bridge to transplantation in adults. This seems to be an attractive pathway for critically ill advanced heart failure patients waiting on the transplant wait list to get a heart very quickly it raises many questions about the feasibility of such an approach in the population. Though there is a very small portion of the

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