Margaret is a 76yo female with a history of COPD and emphysema, treated with home O2 for several years. Notably she is a non-smoker, with her only exposure being second hand from her husband. She presented with increased fatigue and weight loss, and was found on work-up to have a mediastinal mass partially obstructing her left pulmonary artery, and suggestive of fibrosing mediastinitis or lymphoma, as well as some adenopathy, and some possible filling defects in the distal PA branches. However a PET scan was negative for metabolic activity suggestive of malignancy, so she underwent surgical exploration. She was found to have a laminated thrombus in the LPA which required CPB and a brief period of deep hypothermic circulatory arrest to complete the thromboembolectomy. She required epinephrine and norepinephrine to come off CPB, and was then taken to the ICU. Overnight she had increasing hemodynamic instability including a episode of atrial fibrillation with rapid ventricular response. Because of her gradually increasing pressors and poor peripheral perfusion, an echo was ordered, and you are consulted for possible ECMO support.