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In this episode, we discuss the utility of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) for the temporary management of biventricular failure and cardiogenic shock requiring full cardiopulmonary support. Here, we define the types of ECMO and describe the unique physiology of this mechanical circulatory support platform, as well as review the potential complications and management strategies. Most notably, we highlight indications for and contraindications to the use of VA-ECMO and review the importance of patient selection.\xa0 Lastly, we discuss de-escalation and de-cannulation strategies for patients on VA-ECMO as a bridge to recovery. \n\n\n\nJoin Dr. Amit Goyal (CardioNerds Cofounder and FIT at Cleveland Clinic), Dr. Yoav Karpenshif (Series Co-chair and FIT at University of Pennsylvania), and Dr. Megan Burke (Episode FIT Lead and FIT at University of Pennsylvania) as they learn about how to care for some of our sickest patients from Dr. Ann Gage, interventional and critical care cardiologist at Centennial Heart. At the beginning of the episode, enjoy a message from the very first CardioNerds Scholar, Dr. Katie Vaughan (Chief Resident and soon Cardiology Fellow at BIDMC). Episode notes were developed by Dr. Megan Burke. Audio editing by CardioNerds Academy Intern, Hirsh Elhence.\n\n\n\nThe CardioNerds Cardiac Critical Care Series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs,\xa0Dr. Mark Belkin,\xa0Dr. Eunice Dugan,\xa0Dr. Karan Desai, and\xa0Dr. Yoav Karpenshif.\n\n\n\n\n\nPearls \u2022 Notes \u2022 References \u2022 Production Team\n\n\n\n\n\n\n\n\n\nCardioNerds Cardiac Critical Care PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll\n\n\n\n\n\nCardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron!\n\n\n\n\n\n\n\n\n\nPearls and Quotes - Biventricular Failure and the Use of VA-ECMO \n\n\n\n\nVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a form of temporary mechanical circulatory support that can do the work of both the heart and lungs.\n\n\n\nThe ECMO circuit is a narcissist, i.e. cannulas are named in reference to the circuit and not the patient (\u201cinflow\u201d vs \u201coutflow\u201d).\n\n\n\nThe decision to utilize ECMO should be made by a multidisciplinary shock team and patient selection is KEY!\n\n\n\nECMO physiology rule #1: VA-ECMO increases LV afterload\n\n\n\nPatients on VA-ECMO should be monitored with a PA catheter and an arterial line in the right arm\n\n\n\n\nShow notes - Biventricular Failure and the Use of VA-ECMO \n\n\n\nNotes drafted by Dr. Megan Burke.\n\n\n\n1. What is ECMO and what are the different types?\n\n\n\n\nExtracorporeal membrane oxygenation (ECMO) is a temporary form of mechanical life support that comes in two flavors: veno-arterial, or \u201cVA\u201d and veno-venous, or \u201cVV.\u201d\xa0\n\n\n\nVV-ECMO supports extracorporeal gas exchange in the setting of acute respiratory failure\n\n\n\nVA-ECMO provides full circulatory support in addition to gas exchange, doing the work of both the heart and lungs.\xa0\n\n\n\n\n2. What are the components and \u201canatomy\u201d of the VA-ECMO circuit?\n\n\n\n\nThe circuit is made up of the following major components:\n\nVenous (inflow) cannula\n\n\n\nCentrifugal Pump\n\n\n\nOxygenator (also responsible for CO2 removal)\n\n\n\nArterial (outflow) cannula\n\n\n\n\n\nThe cannulas are named in reference to the ECMO circuit, not the patient. Dr. Gage suggests that we think of the ECMO circuit (and mechanical circulatory support in general) as narcissistic, i.e. flow is always in reference to the device.\n\n\n\nGas exchange happens in the oxygenator. In the oxygenator blood flows through thin filaments that allow for diffusion of oxygen and carbon dioxide. Gas flows in the opposite direction of blood flow to maximize diffusion through the countercurrent effect. Oxygenation is determined by rate of blood flow through the oxygenator and FiO2 delivered. Carbon dioxide removal is determined by rate of countercurrent gas flow,