George’s heart is fixed and working well, and the risk of bleeding on ECMO several days out from surgery, even with heparin anticoagulation, is not a contraindication. He has isolated acute aspiration pneumonitis / pneumonia with profound hypoxemia, despite a relatively benign looking CXR. Occasionally patients with some acute pulmonary inflammatory insult will display dramatic intrapulmonary shunting seemingly out of proportion to the CXR. This has been observed with some influenza infections, with aspiration or chemical inhalation injury, and with fat emboli during orthopedic procedures, as examples. As a general rule, in the absence of a secondary bacterial pneumonia, these patients do very well on VV ECMO, allowing some time for the inflammatory response to resolve. The extensive intrapulmonary shunting appears to occur globally throughout both lungs, despite what may be a “local” injury. While some centers have maximal age limits for ECMO, there have been other centers with very good results in patients over 70 and even over 80, when the decision was based on “physiologic” rather “chronologic” age. A previous unpublished search of the ELSO database used for application in a clinical decision at an ELSO center showed survival statistics in the octogenarian group on VV ECMO for respiratory failure comparable to the younger groups of patients, almost certainly because of very careful patient selection in the older group. So George was felt to be a good candidate for VV ECMO support, which he received, with a RFV drainage cannula, and a left subclavian vein infusion cannula (The RIJ was not available related to access for his recent cardiac surgery). He was anticoagulated with heparin and treated with the antifibrinolytic Amicar (monitoring with the TEG-LY30), without bleeding complications. He was off ECMO in a week and recovered to be discharged to home.