766833

research-article2018
PRF0010.1177/0267659118766833PerfusionVogel et al.

Original paper

Perfusion
2018, Vol. 33(1S) 57­–64
Veno-arterio-venous ECMO for septic © The Author(s) 2018
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cardiomyopathy: a single-centre experience sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0267659118766833
https://doi.org/10.1177/0267659118766833
journals.sagepub.com/home/prf

Dominik J. Vogel,1 Josie Murray,1 Adam Z. Czapran,1

Luigi Camporota,1 Nicholas Ioannou,1 Chris I. S. Meadows,1
Peter B. Sherren,1 Kathleen Daly,1 Nigel Gooby2 and Nicholas Barrett1

Abstract
Introduction: The role of extracorporeal support for patients with septic shock remains unclear.
Methods: We conducted a retrospective analysis of our single-centre experience with veno-arterio-venous extracorporeal
membrane oxygenation (VAV ECMO) in adult patients with severe respiratory failure and septic cardiomyopathy. Clinical
data was extracted from electronic medical records including a dedicated ECMO referral and follow-up database.
Results: Twelve patients were commenced on VAV ECMO for septic cardiomyopathy for a median of four days (IQR 3.0
to 5.3) between 01/2014 and 12/2017. Five patients (41.7%) had a cardiac arrest prior to initiation of ECMO support. At
baseline, median left ventricular ejection fraction was 16.25% (IQR 13.13 to 17.5) and median PaO2/FiO2 ratio was 9 kPa
(IQR 6.5 to 12.0) [67.50 mmHg (IQR 48.75 to 90.00)]. The survival rate to hospital discharge for VAV ECMO was 75%
in this cohort. None of the surviving patients died within the follow-up period (median six month).
Conclusion: VAV ECMO is a feasible rescue strategy for a small proportion of patients with combined respiratory and
cardiac failure secondary to septic shock with septic cardiomyopathy. We provide a detailed report of our experience with
this technique. Further research is required comparing the different extracorporeal strategies directly to conventional
resuscitation and against each other.

Keywords
Extracorporeal life support; Extracorporeal membrane oxygenation (ECMO); Veno-arterio-venous extracorporeal
membrane oxygenation (VAV ECMO); Septic cardiomyopathy; Septic shock; Severe respiratory failure; Acute heart failure

Introduction
The role of extracorporeal membrane oxygenation
(ECMO) as a supportive therapy for adult patients
with septic shock remains unclear. Veno-venous (VV)
ECMO corrects hypoxaemia, hypercapnoea and pH,
which may improve cardiovascular function through a
reduction in pulmonary arterial hypertension, but
does not specifically provide mechanical haemody-
namic support. Veno-arterial (VA) ECMO has been
described as a potential rescue therapy for concomi-
tant cardiac failure, however, only in small cohorts and
with a high variability in outcome. 1, 2 The use of hybrid
configurations with venous drainage and divided
respiratory function. However, some patients with
severe pneumonia have a secondary septic cardiomy-
opathy and in this group, a hybrid VAV configuration
can be used. We report the outcomes of a cohort of
patients established on VAV-ECMO with combined
respiratory and cardiac failure secondary to septic
shock with septic cardiomyopathy.
1Department of Critical Care, Guy’s and St Thomas’ NHS Foundation
Trust, Westminster Bridge Road, London, UK
2Department of Clinical Perfusion, Guy’s and St Thomas’ NHS

return flow to arterial and venous cannulae (VAV
ECMO) has been reported in patients with a combina-
tion of various acute heart and lung pathologies. 3, 4
Hybrid configurations are usually commenced in
response to upper and lower body differential oxygen-
ation as cardiac function recovers in advance of
Foundation Trust, Westminster Bridge Road, London, UK
Corresponding author:
Dominik J. Vogel, Department of Critical Care, Guy’s and St Thomas’
NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH,
UK.
Email: dominik.vogel@gstt.nhs.uk
58 Perfusion 33(1S)

Methods Table 1.  Showing baseline demographic and physiologic data

of patients subsequently commenced on VAV ECMO support.
A retrospective, single centre, uncontrolled case series Variables are given as median with inter-quartile range shown
was undertaken. Institutional approval was obtained in brackets. Baseline pulse pressure is given as worst value
within the last six hours prior to VAV ECMO initiation (as
(reference number: 7979) and need for individual
included in the SAVE score). Primary diagnosis leading to
informed consent was waived. The study qualified as a septic shock (n=12) and the identified pathogens of eleven
service evaluation as defined by the UK NHS Health patients are shown. Both cases of influenza were accompanied
Research Authority (NHS HRA) and therefore did not by an MSSA superinfection. The case of MRSA was also
require review by a research ethics committee. confirmed to be positive for Panton Valentine leukocidin.
A retrospective analysis of our prospectively recorded Results of the patient with multiple bacterial growth were
ECMO database was performed to identify the suitable not included in this table. SOFA: sequential organ failure
assessment, APACHE II: acute physiology and chronic health
patients and subsequently clinical data was extracted
evaluation II, SAVE: survival after veno-arterial ECMO, LVEF: left
from electronic medical records (ICIP, Philips – The ventricular ejection fraction, MSSA: methicillin sensitive Staph.
Netherlands). Data recorded included demographics, aureus, MRSA: methicillin resistant Staph. aureus.
underlying pathology and co-morbidities, data related
to the ECMO course and cardiac function, including Baseline at referral  
calculation of the SAVE score. 5 Patients who required Age 40.5 years (23.75 to 50)
extracorporeal circulatory support for reasons other Sex 7 female, 5 male
than septic cardiomyopathy were excluded. Plateau pressure (cmH2O) 31 (26.5 to 36)
PEEP (cmH2O) 15 (12.5 to 16.5)
FiO2 (%) 100 (80-100)
Results PaO2 (kPa) 9.1 (6.4 to 9.8)
P/F ratio 9 (6.5 to 12.0)
Patients PaCO2 (kPa) 7.4 (5.8 to 9.0)
Heart rate (bpm) 129 (120 to 130)
From 01/01/2014 to 20/12/2017 a total of 324 patients Systolic blood pressure (mmHg) 90 (81.5 to 101)
were successfully commenced on VV ECMO, of whom Diastolic blood pressure (mmHg) 52.5 (50.3 to 58)
19 (5.9%) required additional extracorporeal support Mean arterial blood pressure 66.0 (60.5 to 69.5)
(mmHg)
for cardiac failure (VAV ECMO). The clinical notes of Noradrenaline (mcg/kg/min) 0.77 (0.49 to 0.89)
these 19 patients were analysed. Seven patients were pH 7.10 (7.08 to 7.22)
excluded (mitral valve thrombosis n=1, amniotic fluid BE (mEq/L) –9.8 (–12.2 to –7.3)
embolus n=1, cardiogenic shock post myocardial infarc- WCC (x109/l) 11.0 (2.5 to 16.0)
tion n=1, mixed overdose n=2, post cardiotomy n=2). CRP (mg/dl) 199 (61.5 to 293)
Lactate (mmol/l) 5.0 (3.85 to 6.05)
In total 12 patients were commenced on VAV ECMO
Creatinine (μmol/l) 99.5 (70.3 to 265.0)
for septic cardiomyopathy. All twelve patients were INR 1.6 (1.3 to 1.8)
retrieved from referring hospitals on mobile ECMO Baseline at admission  
commenced by an intensivist-led retrieval team. 6 PCT (ng/ml) 100 (15.8 to 100)
Baseline data at referral and outcome-prediction scores Median SOFA score 10 (7.5 to 11.25)
are shown in Table 1. Four patients (33.3%) were Median APACHE II score 23.5 (19.5 to 24)
Baseline prior to cannulation  
retrieved on VV ECMO and arterial cannulation was of the ‘A’ limb
subsequently performed in our unit. Eight patients were Patients with cardiac arrest 5 (41.7%)
retrieved on VAV ECMO, one of whom initially received Pulse pressure (mmHg) 16 (0 to 27)
VV support but was converted to VAV after a short SAVE score –5.5 (–9 to –2.75)
observation period prior to transfer. Five patients LVEF (%) 16.25 (13.13 to 17.5)
Primary diagnosis  
(41.7%) had a cardiac arrest requiring CPR prior to ini-
Community acquired pneumonia 8
tiation of ECMO support. Hospital acquired pneumonia 2
The standard cannula configuration was a 60cm, Fournier gangrene 1
25Fr multi-stage access cannula (Biomedicus, Overwhelming post-splenectomy 1
Medtronic, Minnesota, USA) inserted via the left femo- infection
ral vein, a 50cm, 23 Fr venous return cannula Pathogen  
Streptococcus pyogenes 3
(Biomedicus, Medtronic, Minnesota, USA) inserted via Streptococcus pneumoniae 3
the right femoral vein and a 17 Fr arterial return can- Staphylococcus aureus 3
nula (Biomedicus, Medtronic, Minnesota, USA)  MSSA 2
inserted via the right femoral artery. A 7 or 8 Fr rein-  MRSA 1
forced backflow cannula (Arrow, Denver, USA) was Influenza 2
Escherichia coli 1
placed in the common femoral artery to provide retro-
Pseudomonas aeruginosa 1
grade perfusion of the leg, using ultrasound guidance
Vogel et al. 59
and a Seldinger technique. Standard configuration was
established in eleven (11/12) patients. One patient was
cannulated with a 21 Fr femoral access cannula, a 21 Fr
femoral venous cannula and a 15 Fr left femoral arterial
return cannula due to small body habitus (150cm, 45kg).
Vasoconstrictor and inotropic support
All patients received noradrenaline; hourly rates are
shown in Figure 1. Furthermore, every patient received
a continuous infusion of levosimendan at a rate of 0.10
micrograms/kilogram/hour, commenced either prior to
or during VAV-ECMO support. Five (41.7%) patients
received additional support with vasopressin.
Adrenaline, dobutamine or milrinone were given in two
(16.7%) patients, respectively. Figure 2 shows develop-
ment of serum lactate concentration relative to time of
VAV ECMO initiation.
Cardiac support and monitoring
All twelve patients had a baseline transthoracic echocar-
diogram showing severe left ventricular systolic impair-
ment. Median left ventricular ejection fraction (LVEF)
at time of VAV cannulation was 16.25% (IQR 13.13 to
17.5). In eight patients (66.7%) echocardiographic evi-
dence of significant right ventricular impairment was
found.
As part of the routine weaning assessment, aortic
valve time velocity integral (AV VTI) was measured
using continuous wave Doppler.7 The mean AV VTI
prior to de-cannulation from arterial support was
17.7cm (IQR 16.7 to 19) and median LVEF was 41.25
(IQR 34.38 to 43.75) on ≤ 1l/min arterial flow. All nine
patients who survived had an echocardiogram showing
their left ventricular systolic function recovered to nor-
mal (LVEF 55-60%). First normal LVEF was docu-
mented after a median of nine days (IQR 4 to 12 days).
All three patients who subsequently died had an improv-
ing LV function, compared to their baseline LVEF, doc-
umented prior to death (LVEF 40, 40 and 50%).
One patient underwent diagnostic coronary angiog-
raphy (excluding coronary artery disease), and insertion
of an intra-aortic-balloon-pump (IABP) to support left
ventricular venting post initiation of VAV-ECMO after
echocardiography had shown a dilated left ventricle.
IABP remained in situ for 5 days. None of the remaining
patients had other types of mechanical cardiac support,
left-ventricular decompression, or diagnostic or thera-
peutic cardiac interventions whilst on VAV ECMO sup-
port. One further patient underwent an endomyocardial
biopsy after decannulation from extracorporeal
support. In this case, cardiac myocytes were viable with-
out hypertrophy, disarray, significant inflammation,
fibrosis, granulomata or deposition of iron, and Congo
red staining was negative for amyloid.
Pathogens and antimicrobial agents
A distinct causative pathogen was identified in eleven
(91.7%) patients, with gram-positive cocci accountable
for the majority of cases (75%). Two patients had a
staphylococcal superinfection on the background of
influenza. One patient had multiple bacterial growth
(Staph. aureus, streptococci and gram-negative rods)
detected from a sample obtained with a non-directed
bronchoalveolar lavage prior to retrieval but no further
positive bacterial cultures; PCR revealed herpes simplex
virus and rhinovirus. Table 1 shows the primary source
of sepsis and the identified pathogens. All patients had
been started on empirical broad-spectrum antimicro-
bial agents prior to referral and this regimen was
adjusted according to local guidelines or available results
on admission. There was no evidence that any of the
causative pathogens was not covered by the agents
administered prior to initiation of VAV-ECMO.
Inflammatory markers are shown in Figure 3.
According to our local guidelines, patients with sep-
tic shock are treated with a combination of antibiotics
including a regimen targeting ribosomal protein synthe-
sis. In the first 48 hours following ECMO initiation,
6/12 (50%) patients received gentamicin, 7/12 (58.3%)
received macrolides, 3/12 (25%) received clindamycin
and 9/12 (75%) received linezolid. Additional support-
ive therapies included immunomodulation/toxin scav-
enging with intravenous immunoglobulin in 10/12
(83.3%) patients (median total dose of 2g/kg, range
1-3g/kg), hydrocortisone infusion 8mg/hour in 10/12
(83.3%) patients and high dose Pabrinex® (vitamin B1,
2, 3, 6 and C) in 7/12 (58.3%) patients.
Complications
One patient in this cohort developed an ischaemic right
leg after arterial cannulation. Due to extreme vasocon-
striction the insertion of the right femoral artery back-
flow cannula had failed. The patient underwent surgical
extraction of the ECMO cannula, embolectomy and fas-
ciotomy, and the ECMO circuit was simultaneously
reconfigured to a left femoral arterial return. The patient
subsequently died when therapy was withdrawn after
cerebral oedema led to brain herniation. Another
patient required transfusion of red cells for pronounced
bleeding from the arterial ECMO cannula site on the
background of disseminated intravascular coagulopa-
thy, at a later stage requiring surgical intervention after
ongoing bleeding post de-cannulation. Two patients
developed a neurologic deficit secondary to ischaemic
60 Perfusion 33(1S)

Figure 1.  Showing mean intravenous noradrenaline dose administered during the first three days on VAV ECMO support. Time
‘zero’ indicates time of cannulation. Bars indicate standard error of the mean.

strokes. Both survived; one with a residual right-sided
weakness and right inferior quadrantonopia, the other
made a full neurological recovery. One patient survived
with significant disability after development of bilateral
lower limb ischaemia and a splenic infarct in the initial
period of sepsis with high vasoconstrictor requirements
and at a later stage underwent bilateral below knee
amputation.
Outcome
An overview of outcome in our cohort is shown in
Table 2. Patients required VAV ECMO for a median of
96 hours (IQR 71.25 to 126). Three patients (25%) died
after treatment - including VAV ECMO - was with-
drawn (after two, four and five days, respectively) due
to futility or devastating prognosis: two with irresolv-
able multi-organ-failure and one with cerebral oedema
leading to brain herniation. Nine (75%) patients sur-
vived to successful de-cannulation from VAV ECMO
and none of these died within the follow-up period
(median six month).
Prediction and comparison of outcome
SOFA, APACHE II and SAVE scores as shown in Table 1
suggest a predicted probability of survival of 50%
(median initial SOFA score 10), 50-55% (median
APACHE II 23.5) and 30% (median SAVE score -5.5). 5,
8, 9 The SAVE score was calculated using available date
within the last six hours prior to cannulation of the arte-
rial limb, regardless whether patients were converted
from VV ECMO or had arterial support initially.
Discussion
In this retrospective, observational, case series, patients
with severe respiratory failure and septic shock due to
septic cardiomyopathy, were managed using hybrid
VAV ECMO with survival which surpassed that pre-
dicted using the currently available scoring systems.
These results are similar to those reported by Bréchot
et al who found a survival rate of 71% in a cohort of 14
patients receiving VA ECMO for profound septic car-
diomyopathy. 1 However, other reports have indicated a
Vogel et al. 61
Figure 2.  Showing box-and-whisker plots for serum lactate
concentration for the last six hours prior to, as well as for each
six-hour period after initiation of VAV ECMO, for three days.
For each six-hour period the worst recorded lactate for each
patient was used for the analysis.
somewhat lower survival with one group reporting a
21.9% survival to hospital discharge. 2 Septic cardiomy-
opathy has also previously been demonstrated to be an
independent predictor of mortality, although with
inconsistency in the available literature. 10, 11
The degree of acute heart failure in this cohort was
severe. The median left ventricular ejection fraction at
commencement of VAV ECMO was 16% and was asso-
ciated with demonstrable shock manifest by organ fail-
ure and hyperlactataemia. Cardiac recovery occurred
over a median of 4 days as demonstrated by an improve-
ment in the LVEF to 41% allowing decannulation from
cardiac support. In all survivors cardiac function had
returned to essentially normal by echocardiographic
criteria by ICU discharge (LVEF 55-60%). In patients
who did not survive, significant improvement was seen
in cardiac function during their stay and primary car-
diac dysfunction was not the cause of death for any
patient. Although only one patient had an endomyocar-
dial biopsy, this demonstrated that cardiac myocytes
were viable and this is consistent with the clinical
improvement seen in the cohort. During the period of
VAV ECMO support, regular transthoracic echocardi-
ography was performed to ensure early detection of left
ventricular enlargement. In this cohort, there was only
limited LV dilatation requiring additional mechanical
support with an intra-aortic balloon pump in one
patient and no patients required an impella or septos-
tomy. Furthermore, arterial support was required for
only 4 days. Compared with ischaemic cardiomyopathy,
this rate of improvement is quicker and the need for
additional support is lower. 12-14 This cohort suggests
that the septic cardiomyopathy is entirely and relatively
rapidly reversible provided support can be given to
maintain oxygen delivery to the body. These results are
in agreement with those of Bréchot et al who also dem-
onstrated an improvement in cardiac function over the
duration of the inpatient stay. 1
VAV ECMO provides support in a situation of com-
bined refractory respiratory and cardiac failure with the
returning blood flow from the pump being divided by a
‘Y’ connector into two lines connected to the femoral
vein and artery, respectively, supplying oxygenated blood
towards the right atrium and retrogradely into the aorta
via the femoral artery simultaneously. The distribution
of flow can be constantly adjusted with a gate clamp
according to the patient’s cardiopulmonary status thus
ensuring pulsatile flow and at the same time preventing
differential hypoxaemia (Harlequin Syndrome). 15 This
can be guided by monitoring arterial blood gas samples
obtained from a right radial arterial line, right hand pulse
oximetry and cerebral near infrared spectroscopy. VAV
ECMO is commonly instituted when there is a risk of
differential hypoxaemia occurring, when cardiac recov-
ery precedes lung recovery, as the heart ejects de-oxy-
genated blood. In the current series, cardiac support was
required for a median of 4 days whilst respiratory sup-
port was required for a median of 9. Five patients were
commenced on VV ECMO and then converted to VAV.
In these cases, there was either significant deterioration
in cardiac function over the first few hours of the ECMO
course, or time was given to assess the response of
impaired myocardial function to VV ECMO alone;
improved myocardial function may occur following cor-
rection of significant hypoxaemia and respiratory acido-
sis, reduced intrathoracic pressures and improved left
ventricular performance secondary to improved right
ventricular function due to interdependence. It would of
course have been possible to commence with VA ECMO
and then subsequently convert to VV should it be
required. The VAV configuration was chosen as the time
62 Perfusion 33(1S)

Figure 3.  Showing white cell count (WCC) in 109/l, C-reactive protein (CRP) in mg/dl and procalcitonin (PCT) in ng/ml on admission
and on day-3, respectively. Note that on admission PCT was > 100 ng/ml in eight patients and still >100 ng/ml in five patients on day-3.
Also, note the leukopenia on admission in five patients. Left ventricular ejection fraction (LVEF) is shown as box-and-whisker plot for
baseline at VAV ECMO initiation, prior to de-cannulation of the arterial limb and (for survivors) prior to ICU discharge.

Table 2.  Showing outcome of all twelve patients with times as mainly staphylococcal, or streptococcal, with two
median days (IQR in brackets). cases of superinfection of Influenza. A causative
Outcomes   organism was identified in 11 cases using a mixture
of traditional microbiological tests (culture) and
Time on VAV ECMO (days) 4 (3.0-5.3) advanced molecular diagnostics (16S PCR) on
Total time on ECMO (days) 9 (7.5 to 15.5) specimens obtained by bronchoalveolar lavage.
Time until LVEF normal (days) 9 (4 to 12) Staphylococcal and streptococcal species are known
Time on ventilator (days) 15 (6.5 to 32.5) to produce severe infections, made worse by the pres-
Time on renal-replacement-therapy (days) 5 (2.5 to 22.5) ence of toxins which enhance tissue necrosis and
Length of ICU stay (days) 21 (11 to 38)
cause leucocytosis. 16, 17 The degree of host response
Length of hospital stay (days) 62 (36.5 to 67.5)
was overwhelming with two thirds of cases having a
Predicted hospital survival by SAVE score 30% (30 to 42)
risk class
procalcitonin over 100ng/mL and nearly half the
Discharged alive from ICU 9/12 (75%) cohort having profound leucopenia. These are thought
Discharged alive from hospital 9/12 (75%) to be indicators of both the degree of sepsis and the
Alive at follow-up 9/12 (75%) presence of toxin producing organisms. 18-20
There were two significant complications related to
cannulation. One in a patient in whom a backflow
to recovery of cardiac function is variable and unpredict- cannula could not be placed. This patient was re-can-
able; having the venous return in situ also allows for pre- nulated following return to the hospital by vascular
served cerebral oxygenation. The additional benefit of surgeons who placed a graft on the contralateral fem-
having the venous cannula at the beginning of the ECMO oral artery. The other was secondary to bleeding,
run, is that re-cannulation to a VV configuration does although the patient had a fulminant coagulopathy.
not have to happen in an urgent manner, nor while the Cannulation for peripheral VAV ECMO was per-
patient is anticoagulated or has an ECMO-related coagu- formed at the referring hospital by a consultant inten-
lopathy. sivist-led mobile ECMO service using ultrasound and
The patient cohort was found to have a preponder- fluoroscopic guidance, a strategy previously shown to
ance of community acquired bacterial pneumonia, be safe and effective for the provision of VV ECMO. 6,21
Vogel et al. 63
When non-surgical cannulation is undertaken, it is
important to have the availability of surgeons able to
repair or re-cannulate in the event of complications.
Arterial de-cannulation was performed in the hybrid
vascular theatre suite by vascular surgeons and venous
de-cannulation by intensivists on the critical care unit.
Other complications included cerebral haemorrhage
and spinal cord infarction. It is known that arterial
support can result in embolic and haemorrhagic cer-
ebral events, however it is also known that critically ill
patients requiring VV ECMO have a higher incidence
of intracerebral bleeding. 22 In patients requiring
ECMO support it can be difficult to distinguish
whether complications appear as a consequence of the
extracorporeal intervention or of the underlying
severe pathology and critical illness. 22
There are significant limitations to this study. It is a
small retrospective uncontrolled case series with intrin-
sic bias as the mode of therapy was chosen by clinicians.
Prospective work is required to truly understand the
outcomes associated with VAV ECMO and septic car-
diomyopathy.
Conclusion
Sepsis induced cardiomyopathy was described as revers-
ible cardiac dysfunction in the context of septic shock
potentially linked to endotoxin release. 23 The available
evidence for the use of VAV ECMO in this setting is lim-
ited to case reports. 24
We report a favourable outcome with a survival rate
of 75%, in a small cohort of patients supported with
VAV ECMO, exceeding the expected survival probabil-
ity estimated by common scoring systems. This is a
challenging group of patients who require advanced
experience and expertise in the initiation, maintenance
and management of potential complications of extra-
corporeal support. In a high volume severe respiratory
failure centre, VAV ECMO is a feasible rescue strategy
for a small proportion of patients.
Further research is required comparing the different
extracorporeal strategies for septic cardiomyopathy
directly to conventional resuscitation and against each
other.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: NA Barrett has received funding for education and
research from Maquet, Alung and Corpak.
ORCID iD
Dominik J. Vogel https://orcid.org/0000-0001-6522-0547
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