Prior to the ECMO era, failure to wean from CPB with maximal inotropes and an IABP led to the patient dying in the operating room. In present day, however, transition to VA ECMO provides the heart time to recover from a preoperative ischemic insult, a long cardioplegic arrest period, a long complex operation, or some combination of the above. Omar fortunately had excellent targets and three good bypass grafts placed, and did recover function with a moderately improved EF (25-30%) to successfully be weaned from ECMO. His course was complicated by acalculus cholecystitis, HIT and a sternal would infection that required two reconstructive procedures, but he eventually was discharged to rehab, and then to home.

Survival is reasonable in patients who fall into a few categories:

• At the end of the operation, the heart is repaired, revascularized, etc. and the poor function is believed to be due to the insult of the preoperative unrepaired or untreated condition, added to the stress of surgery, CPB and cardioplegic arrest. Allowing the heart to rest in an empty, vented, perfused state, ideally without the stress of high dose inotropes, maximizes the likelihood of recovery and successful weaning off ECMO.

• Patients whose hearts were not able to be repaired for whatever reason, will only benefit from ECMO if they are candidates for bridge to some other long term support device like VAD or TAH, and then possibly to heart transplant.

• In the emergency setting it may not be possible to have sufficient information to predict the patient’s chances of recovery, or if they meet the criteria for either destination VAD support or heart transplantation. These patients are appropriately supported as “bridge to decision”.

• While it is not ideal to transition a patient to ECMO who has a very low chance of recovering cardiac function (no suitable bypass targets identified), or is clearly not a candidate for VAD or transplant, admittedly this is not uncommon in these circumstances. Often the goal is simply to get the patient to the ICU where the circumstances can be explained to the family, and they can visit the patient prior to withdrawal of support. Some argue that this actually makes it easier for the family to deal with (and perhaps the surgical team as well) than a death in the operating room. The ECMO team often sees this as a courtesy service to their cardiothoracic surgery colleagues after a long, difficult and complex operation to try to salvage the patient. On the other hand, it is not inherently wrong to decline such support, particularly if your center is tight on staff or circuits.