Scoping review of contemporary adult venoarterial extracorporeal membrane oxygenation (VA ECMO) selection criteria and decision-making mechanisms.

Adult venoarterial extracorporeal membrane oxygenation (VA ECMO) is a costly life support therapy, where patient selection remains a significant hinge-point in determining patient outcomes. Despite this, few sites have formalized patient selection criteria, and even fewer have a robust multidisciplinary ECMO team to determine patient candidacy. Analyzing current literature revealed weaknesses in existing research on VA ECMO patient selection criteria. Significant issues include the use of small sample sizes, lack of randomized controlled trials, lack of personalization of ECMO initiation decisions, study heterogeneity, and inclusion of patients who received ECMO without including patients who were considered for but not given ECMO. Among the available studies, the Survival After Venoarterial ECMO (SAVE) score has shown the greatest promise in selecting VA ECMO patients, excluding those undergoing extracorporeal cardiopulmonary resuscitation (ECPR) and postcardiotomy (PC) ECMO. The SAVE score has demonstrated good discrimination in non-ECPR and non-PC ECMO groups. Further research is needed on the predictive value of SAVE score risk classes and the discrimination of the SAVE score excluding PC ECMO and ECPR groups. The modified SAVE score, which also includes lactate assessment, has shown the greatest promise for selecting ECPR and PC ECMO patients for VA ECMO. The modified SAVE score requires more external validation. Site-level research indicates that consultation with a multidisciplinary ECMO team, which collectively makes decisions about ECMO candidacy, has resulted in significantly improved patient survival outcomes compared with a one- or two-physician decision-making mechanism for VA ECMO initiation. The ECMO team approach is a rich area for future research, and sites should publish their patient outcomes before and after implementation.