Margaret has two potential cautionary “red flags” regarding ECMO candidacy. Some centers have an upper age limit which may be 65 or 70, while others try to evaluate the patient based on “physiologic age” rather than just chronologic age. The bigger issue is the use of home O2, which is generally considered a contraindication for ECMO support. However, that usually pertains to VV ECMO for respiratory support since patients with severe enough underlying lung disease to require home O2 are very unlikely to survive another respiratory insult that severe enough to warrant ECMO consideration. Margaret’s circumstances are a bit unique. She was diagnosed with a specific problem and provided informed consent after carefully considering the risks explained to her. Once the team had completed the operation successfully, she was left with significant pulmonary hypertension that is very common after a thromboendarterectomy, especially with the use of deep hypothermia, but which frequently improves or resolves with time and therapy (and support as needed). Her echo confirmed normal LV function and a very sick RV due to the elevated pulmonary vascular resistance.

Margaret was taken to the OR for open femoral cannulation for VA ECMO including a T-graft to the femoral artery to avoid lower extremity ischemia. Once her RV was decompressed, as confirmed by echo, she improved dramatically including dramatically increased urine output. The flow was weaned over two days and she was being considered for decannulation, but an echo showed the RV was again somewhat distended. She was treated with nitric oxide and then started on Sildenafil. After three days of treatment the nitric oxide was weaned and she was successfully taken off ECMO. A few days later she was extubated to her nasal cannula O2, and subsequently transferred to rehab for continued recovery prior to returning home.