Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a temporary mechanical circulatory support device capable of providing robust cardiopulmonary support for days to weeks, most commonly in the setting of refractory cardiogenic shock or cardiac arrest as a bridge to recovery or heart replacement therapies (HRT, e.g., durable left ventricular assist device or cardiac transplantation) [1]. Given the complications associated with prolonged use of VA-ECMO, it is imperative to institute systematic weaning strategies. In this article, we review our standardized approach to VA-ECMO weaning in adult patients.

VA-ECMO supports circulation while treatment of the underlying pathology is prioritized to facilitate successful weaning or bridge to HRT. Because the potential for ventricular recovery is often difficult to ascertain, we advocate that all patients where HRT is a realistic consideration undergo early evaluation even if the intended goal is recovery [2,3,4,5].

Our center favors the use of invasive hemodynamics whenever possible to guide therapy in VA-ECMO. A pulmonary artery catheter provides valuable information about left ventricular (LV) loading conditions [6]. A right upper extremity arterial line should be maintained in all patients with femoral cannulation to facilitate monitoring of pulsatility and oxygenated blood flow to the arch of the aorta [7]. We generally target a cardiac index > 2.2 L/min/m², mean arterial pressure (MAP) 65–80 mmHg, central venous pressure 8–12 mmHg, and pulmonary capillary wedge pressure < 18 mmHg. Arterial blood gas (ABG), lactate, hepatic, and renal function are followed in serial laboratory measurements to assess adequacy of end-organ perfusion.