Extracorporeal membrane oxygenation (ECMO) has been used increasingly for both respiratory and cardiac failure in adult patients. Indications for ECMO use in cardiac failure include severe refractory cardiogenic shock, refractory ventricular arrhythmia, active cardiopulmonary resuscitation for cardiac arrest, and acute or decompensated right heart failure. Evidence is emerging to guide the use of this therapy for some of these indications, but there remains a need for additional evidence to guide best practices. As a result, the use of ECMO may vary widely across centers. The purpose of this document is to highlight key aspects of care delivery, with the goal of codifying the current use of this rapidly growing technology. A major challenge in this field is the need to emergently deploy ECMO for cardiac failure, often with limited time to assess the appropriateness of patients for the intervention. For this reason, we advocate for a multidisciplinary team of experts to guide institutional use of this therapy and the care of patients receiving it. Rigorous patient selection and careful attention to potential complications are key factors in optimizing patient outcomes. Seamless patient transport and clearly defined pathways for transition of care to centers capable of providing heart replacement therapies (e.g., durable ventricular assist device or heart transplantation) are essential to providing the highest level of care for those patients stabilized by ECMO but unable to be weaned from the device. Ultimately, concentration of the most complex care at high-volume centers with advanced cardiac capabilities may be a way to significantly improve the care of this patient population.

2nd Department of Medicine 1st Faculty of Medicine Charles University and General University Hospital Prague Prague Czech Republic

Adult Intensive Care Service The Prince Charles Hospital and University of Queensland Brisbane Australia

Australian and New Zealand Intensive Care Research Centre Monash University Melbourne Australia Physiotherapy Department The Alfred Hospital Melbourne Australia

Cardiothoracic and Vascular ICU Auckland City Hospital Auckland New Zealand Medical Research Institute of New Zealand Wellington New Zealand Australia and New Zealand Intensive Care Research Centre Monash University Melbourne Australia

Cardiothoracic ICU National University Health System Singapore Singapore Paediatric ICU Royal Children's Hospital Melbourne Australia

Cardiothoracic Surgery Department Heart and Vascular Centre Maastricht University Medical Centre Maastricht The Netherlands

Center for Cardiac Intensive Care Capital Medical University Affiliated Anzhen Hospital Beijing People's Republic of China

Clinical Perfusion and Anesthesia Support Services New York Presbyterian Hospital Columbia University Medical Center Morgan Stanley Children's Hospital of New York New York NY USA

Critical Care Department Cairo University Cairo Egypt

Department of Anaesthesia and Intensive Care Papworth Hospital NHS Foundation Trust Cambridge UK

Department of Cardiology European Hospital Georges Pompidou Assistance Publique Hôpitaux de Paris and Sudden Death Expert Center INSERM U 905 Paris Descartes University Paris France

Department of Cardiology Fundación Cardiovascular de Colombia Bucaramanga Colombia

Department of Cardiothoracic Surgery Montefiore Medical Center Albert Einstein College of Medicine New York NY USA

Department of Emergency Medicine Teikyo University Hospital Tokyo Japan

Department of Internal Medicine 2 University Hospital of Regensburg Regensburg Germany

Department of Surgery Columbia University Medical Center New York NY USA

Department of Surgery National Taiwan University Hospital Taipei Taiwan

Department of Surgery University of Michigan Ann Arbor MI USA

Department of Surgical Intensive Care Medicine Nippon Medical School Hospital Tokyo Japan

Division of Cardiac Vascular and Thoracic Surgery Columbia University Medical Center New York NY USA

Division of Cardiology Columbia University Medical Center New York NY USA

Division of Critical Care Medicine Department of Medicine Jay B Langner Critical Care Service Montefiore Medical Center New York NY USA

Division of Pediatric Cardiology Columbia University Medical Center New York NY USA

Division of Pulmonary Allergy and Critical Care Columbia University College of Physicians and Surgeons NewYork Presbyterian Hospital 622 W168th St PH 8E Room 101 New York NY 10032 USA

Hamad Medical Corporation Weill Cornell Medical College in Qatar Doha Qatar

Intensive Care Unit The Alfred Hospital Melbourne Australia

Interdepartmental Division of Critical Care Medicine Departments of Medicine and Physiology Institute for Health Policy Management and Evaluation University of Toronto Research Institute Toronto Canada Division of Respirology Department of Medicine University Health Network and Sinai Health System Toronto General Hospital Toronto Canada

Interdepartmental Division of Critical Care Medicine Departments of Medicine and Physiology Institute for Health Policy Management and Evaluation University of Toronto Research Institute Toronto Canada Extracorporeal Life Support Program Toronto General Hospital Toronto Canada

Keenan Research Center Li Ka Shing Knowledge Institute St Michael's Hospital Toronto Canada Interdepartmental Division of Critical Care Medicine Department of Medicine University of Toronto Toronto Canada

Medical Surgical Intensive Care Unit Hôpital Pitié Salpêtrière Assistance Publique Hôpitaux de Paris 75013 Paris France INSERM Institute of Cardiometabolism and Nutrition UMRS_1166 ICAN Sorbonne University Paris Paris France

Minneapolis Heart Institute Abbott Northwestern Hospital Minneapolis MN USA

Royal Brompton and Harefield NHS Foundation Trust National Heart and Lung Institute Imperial College London London UK

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