title: Venovenous Versus Venoarterial Extracorporeal Membrane Oxygenation for Adult Patients With Acute Respiratory Distress Syndrome Requiring Precannulation Hemodynamic Support: A Review of the ELSO Registry.
abstract: BACKGROUND
  In addition to severe hypoxia and hypercapnia, acute respiratory distress syndrome (ARDS) can present with substantial hemodynamic compromise, requiring inotropic or vasopressor support or both. Either venovenous (VV) or venoarterial (VA) extracorporeal membrane oxygenation (ECMO) can be offered in this situation. However, a contemporary comparison of these two cannulation strategies has yet to be well described.
  
  
  METHODS
  The Extracorporeal Life Support Organization Registry was reviewed for all cases of adult ARDS in patients that required inotropic agents or vasopressors or both before ECMO initiation (2009 to 2013). Pre-ECMO clinical data, ECMO variables, and outcomes were compared, based on initial cannulation strategy (VV or VA ECMO).
  
  
  RESULTS
  Of 717 ECMO runs, there were 591 VV ECMO and 126 VA ECMO cases. Over the study period, the proportion of VA ECMO cases decreased from 20% (n = 37 of 184, 2009 to 2010) to 19% (n = 59 of 312, 2011 to 2012) to 14% (n = 30 of 221, 2013). Conversion from VV ECMO to VA ECMO was 4%. VV ECMO was associated with less gastrointestinal bleeding and hemolysis, but overall rates of bleeding, stroke, and renal failure were similar. Survival to discharge was 58% for VV ECMO in contrast to 43% for VA ECMO (p = 0.002). Multivariable regression analysis revealed VV ECMO to be an independent predictor of survival to discharge relative to VA ECMO.
  
  
  CONCLUSIONS
  In this review of ARDS patients requiring pre-ECMO hemodynamic support, VV ECMO was not associated with worse survival or complication rates compared with VA ECMO. These data suggest that, in appropriately selected patients, it may be reasonable to initially institute VV ECMO support, reserving VA ECMO for conversion for refractory hypotension.
authors.affiliation: Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland. Electronic address: zkon@smail.umaryland.edu.
authors.forename: Zachary N
authors.initials: ZN
authors.lastname: Kon
authors.affiliation: Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Bittle
authors.affiliation: Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Chetan
authors.initials: C
authors.lastname: Pasrija
authors.affiliation: Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Si M
authors.initials: SM
authors.lastname: Pham
authors.affiliation: Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Mazzeffi
authors.affiliation: Department of Shock Trauma Critical Care, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Daniel L
authors.initials: DL
authors.lastname: Herr
authors.affiliation: Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Pablo G
authors.initials: PG
authors.lastname: Sanchez
authors.affiliation: Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
authors.forename: Bartley P
authors.initials: BP
authors.lastname: Griffith
mesh_terms: D000328:Adult; D001158:Arteries; D002404:Catheterization / Q000379:methods*; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D008297:Male; D008396:Maryland / Q000453:epidemiology; D012042:Registries; D012128:Respiratory Distress Syndrome / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D014680:Veins