Background: Extracorporeal membrane oxygenation is an effective life support technology in treating patients with cardiorespiratory failure. It could be used as a bridge to recovery, potentially improving patient outcomes due to cardiopulmonary support. In selected patients, awake insertion of veno-arterial (VA) ECMO might be better for maintaining intrinsic sympathetic tone. Awake VA ECMO cases are rarely reported. Many benefits were noted in this group of patients such as reduced pulmonary complications, improved rehabilitation, and less muscle atrophy and venous thrombosis.

Case Summary: We present a 46-year-old male patient who is known to have dilated cardiomyopathy and insertion of cardiac resynchronization therapy defibrillator (CRTD). Echocardiography and cardiac magnetic Resonance Imaging (MRI) showed severely reduced left ventricle (LV) function with ejection fraction (EF) of 17%. He continued to be symptomatic and started to develop multi-organ failure even with multiple inotropic agents and intra-aortic balloon pump (IABP) support. He was a high-risk candidate for any intervention because of risk of general anesthesia and presence of iatrogenic severe thrombocytopenia. VA ECMO was inserted successfully under local anesthesia as a bridge to transplant, for which he was accepted in an overseas transplant center. Post ECMO insertion, the patient remained awake and his hemodynamics and organ perfusion improved dramatically and was escorted successfully to the transplant center.