I applaud David Platts and colleagues on their comprehensive, timely, and well-written review outlining the role of echocardiography in the assessment of patients requiring extracorporeal membrane oxygenation (ECMO). Given that cardiologists are often involved in the initial assessment and management of these critically ill and unstable patients, I would like to comment that the contraindications discussed are rarely absolute. As experience grows with unusual or complex cases, particularly in otherwise young and previously healthy patients facing impending death, clearly each case needs to be individualized. For example, Platts et al. comment that severe pulmonary hypertension is an absolute contraindication, but we must remember the severe pulmonary vasoconstrictive response to hypoxemia and/or acidosis. In fact, ECMO might even be considered indicated in such cases as a means of infusing physiologic oxygenated blood directly into the pulmonary arteries, with the goal of rapidly breaking a downward hypoxemic or acidosis-induced pulmonary hypertensive crisis. In addition, our experience with salvage venovenous ECMO in patients with evidence of intracranial blood secondary to acute neurologic pathologies suggests a potential role in these carefully selected patients. Although the need for major surgery is often a contraindication to anticoagulation, we have also demonstrated that patients requiring ECMO for overwhelming septic shock can successfully be managed even if they require multiple operative debridements for extensive necrotizing soft tissue infections. Furthermore, Although there is an evolving role for ECMO-assisted cardiopulmonary resuscitation in patients with acute cardiac arrest, if the precipitating cause is a presumed respiratory event, a trial of venovenouse ECMO might be a reasonable approach.

Without a doubt, ECMO is an exciting technology, and as Platts et al. clearly demonstrate, the applications and technology are constantly evolving, as is our understanding of how to manage these patients. There is no doubt that ECMO is expensive, invasive, and resource intensive, and its use must be closely monitored for appropriateness versus futility of care. However, it is critical, as with any evolving salvage tool, in which a life is acutely at risk, that we keep our minds open and rarely consider contraindications absolute.