Optimal timing of venoarterial extracorporeal membrane oxygenation (VA-ECMO) decannulation in pediatric patients with congenital or acquired heart disease remains challenging, particularly when myocardial recovery is uncertain. Some centers delay decannulation after successful separation from ECMO to allow extended observation while maintaining cannula access.

We conducted a single-center retrospective study of patients <18 years of age who underwent delayed VA-ECMO decannulation between 2021 and 2024. Following successful separation from ECMO, cannulas were maintained under standardized anticoagulation, surveillance, and multidisciplinary oversight. Clinical outcomes, procedural complications, vascular findings, and neurologic monitoring results were evaluated.

Fifty-seven patients were included (40% [23/57] female; median age 1.6 months [IQR 0.5-5.3]; median weight 3.7 kg [IQR 3.2-5.4]). Most of the patients had congenital heart disease (49/57, 86%), including 53% (30/57) with single-ventricle physiology, and 72% (41/57) who required postoperative ECMO. Median ECMO duration was 107.1 h (IQR 85.7-166.8), and the median interval between ECMO separation and decannulation was 24.6 h (IQR 20.8-28.8). One patient required reinstitution of ECMO prior to decannulation. No major bleeding events, cannula-site infections, or clinically apparent intraluminal thrombosis occurred during the delayed interval. Postdecannulation imaging identified internal jugular vein thrombosis in a subset of patients, most of which resolved on follow-up. Neurologic monitoring revealed no new abnormalities attributable to the delayed decannulation period.

In pediatric cardiac patients with complex anatomy and uncertain myocardial recovery, delayed VA-ECMO decannulation is safe and feasible. This strategy may provide a controlled transition off mechanical support in selected high-risk patients. Prospective multicenter studies comparing delayed and immediate decannulation strategies are needed.