Extra-corporeal membrane oxygenation (ECMO) is growing in adoption and popularity, as demonstrated by the international registry maintained by the Extracorporeal Life Support Organization (ELSO).

While initially an adaptation of cardiopulmonary bypass and used to salvage sick children with oxygenation problems , its adaptation to the adult population after the introduction of heparin bonded circuits in the early 1990s, was initially for post-cardiotomy support and was associated with poor outcomes.

Frequently in this post-cardiotomy support setting, an intra-aortic balloon pump (IABP) is inserted first.

One article in the current issue, by Djordjevic et al., highlights the experience of ECMO along with IABP.

Despite better weaning rates with IABP + ECMO support compared with ECMO alone, mortality did not differ in the groups. While the numbers in the different groups were not large, this constituted a carefully conducted observational study. IABP has been proposed as a method of left ventricular (LV) decompression to avoid the adverse effects of LV distension syndrome. A ‘one size fits all’ approach is unlikely to be effective, however, as compared with other interventional methods (e.g. Impella [Abiomed, Danvers, MA, USA], apical LV vent), IABP may not provide sufficient offloading for all patients. It has also been shown that in the more stunned left ventricles (pulse pressure <10 mmHg), IABP decreases cerebral perfusion when combined with peripheral veno-arterial (VA) ECMO . Low survival with no difference in the various groups raises the proposition that mechanical support did not alter outcome. Indeed, post-cardiotomy ECMO has been tainted with the dark brush of poor outcomes, with mortality rates in the literature between 60–75% . This suggests that the intervention is bordering on futility, or there is inadequate LV offloading, or, most likely, that it is instituted too late to be effective.