Venoarterial Extracorporeal Membrane Oxygenation in Adults With Septic Shock: Hope or Hype?

Septic shock is associated with significant morbidity and mortality, but a subset of patients with sepsis will experience transient myocardial depression, termed sepsis-associated cardiomyopathy, which markedly increases observed mortality. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support in medically refractory sepsis, survival in patients with VA-ECMO for sepsis has been historically poor. Concerns regarding numerous potential harms associated with VA-ECMO, including further seeding of infection, exacerbation of inflammation and vasoplegia, bleeding, thrombosis, and distal limb ischemia have further tempered enthusiasm in the setting of sepsis. However, there may be a subset of patients with profound sepsis refractory to medical therapy that could potentially derive some benefit from VA-ECMO. This review provides an overview of the pathophysiology, diagnosis, and treatment of sepsis-associated cardiomyopathy and then focuses on the utility of VA-ECMO in this patient population. A summary of the scant published outcomes of VA-ECMO in sepsis-associated cardiomyopathy is provided, followed by a discussion of important management considerations to optimize outcomes in these extremely sick patients, and finally the pros and cons of VA-ECMO in the setting of sepsis are presented. Using available published data and current state-of-the-art practice, we conclude that VA-ECMO may be a reasonable consideration in highly selected patients with low ejection fraction sepsis-associated cardiomyopathy and refractory hypoperfusion in appropriately equipped health care systems, but more supportive data are required before VA-ECMO can be generally recommended in patients with septic shock.