peripheral veno - arterial extracorporeal membrane oxygenation ( va - ecmo ) is increasingly used in acute , severe cardiogenic shock refractory to conventional therapy .
although percutaneous femoral insertion of va - ecmo is straightforward , the procedure is usually performed after intubation under general anaesthesia , and invasive ventilation is continued for the whole period of extracorporeal support . here , we show that va - ecmo can be successfully performed with neither ( non- ) invasive ventilation nor deep analgosedation .
a 51-year - old man with a history of hypertension and diabetes mellitus presented to the local hospital in cardiogenic shock ( blood pressure , 80/40  mmhg ) .
electrocardiography ( ecg ) revealed a ( sub)acute anterior myocardial infarction complicated by complete atrioventricular block and a slow ventricular escape rhythm of 30 beats per minute ( fig .  1 ) .
after initial medical therapy ( volume resuscitation , inotropes ) , the clinical condition allowed urgent transport to an interventional centre . on arrival , immediate transvenous ventricular pacing
echocardiography showed preserved wall thickness , but extensive apical and anteroseptal akinesia and inferior hypokinesia , with a large left ventricular ( lv ) apical thrombus ( left ventricular ejection fraction ( lvef ) , 10  % ) .
1serial electrocardiograms ( upper panel ) and transthoracic echocardiograms ( lower panel ) on presentation ( left ) and on recovery 6 weeks later ( right ) showing a large dilated anterior myocardial infarction with partial recovery of contractile function .
arrow indicates lv apical thrombus , which dissolved over time after therapeutic anticoagulation ( recovery ) .
rv right ventricle , lv left ventricle serial electrocardiograms ( upper panel ) and transthoracic echocardiograms ( lower panel ) on presentation ( left ) and on recovery 6 weeks later ( right ) showing a large dilated anterior myocardial infarction with partial recovery of contractile function .
arrow indicates lv apical thrombus , which dissolved over time after therapeutic anticoagulation ( recovery ) .
rv right ventricle , lv left ventricle since cardiogenic shock persisted , va - ecmo was initiated under local anaesthesia via femoral access ( 25f venous cannula , 19f arterial cannula ) as a bridge to recovery and additional therapy . during the procedure , the patient was fully awake , non - intubated and breathing oxygen through a non - rebreathing facemask .
va - ecmo yielded 4-l / min flow , and a mean arterial pressure of 6070  mmhg was achieved .
an adequately supported circulation was reflected by normal blood gas analysis , lactate levels , venous oxygen saturation and renal function ; sinus rhythm ensued on day 2 .
coronary angiography revealed severe three - vessel disease ( proximally occluded right , significantly stenosed circumflex and subtotally occluded left anterior descending coronary artery ) unattractive for immediate revascularisation .
the clinical course was complicated by obvious signs of pulmonary oedema on serial chest radiographs ( fig . 
2 ) in the absence of dyspnoea ( respiratory rate of 1520 per minute ) and with adequate oxygenation ( sao2 , 97100  % ; pao2 >  100  mmhg ) . therefore , heart failure therapy ( captopril , eplerenone , isosorbide mononitrate ) was tailored with a pulmonary artery catheter ( pac ) and intensified ( furosemide , hydrochlorothiazide ) to accomplish negative fluid balances .
daily gradual tapering of ecmo flow ( l / min ) during weaning off ecmo support ( lower panel ) serial chest x - rays indicating decrease of pulmonary congestion ( upper panel ) .
daily gradual tapering of ecmo flow ( l / min ) during weaning off ecmo support ( lower panel ) after 4 days of va - ecmo under low - dose continued intravenous analgesia ( 1  mg morphine / h ) , support flow was gradually reduced ( 1  l / min per day ) under therapeutic heparinisation and pac monitoring . on day 8 , echocardiography revealed partial lv recovery ( lvef , 25  % ) during normally conducted sinus rhythm ( fig .  1 ) and 1  l / min support flow , allowing weaning off the va - ecmo . in a stable condition ,
the patient was mobilised and discharged from the intensive care unit ( icu ) on day 11 . based on myocardial viability studies ( mid anteroseptal viability on cardiac magnetic resonance perfusion imaging ) ,
a drug - eluting stent was placed in the left anterior descending artery on day 21 , followed by clinical discharge on day 37 .
there is accumulating evidence that severe , refractory cardiogenic shock can be supported by percutaneous va - ecmo as a bridge to recovery , long - term mechanical support and eventually heart transplantation .
yet , va - ecmo is cumbersome , as patients are generally managed and instrumented in the icu with invasive ventilation , analgosedation and feeding via a nasogastric tube .
this renders va - ecmo a complex and invasive therapeutic approach with numerous potential icu - related complications .
in contrast to va - ecmo standard care , we managed this case without intubation , ventilation or significant analgosedation , which has , to the best of our knowledge , not been reported in this way before .
we used pac monitoring for haemodynamic tailoring and strived for optimal filling pressures ( wedge pressures <  15  mmhg ) , while allowing adequate systemic va - ecmo flow . during
va - ecmo weaning , we monitored cardiac recovery by continuously measuring intrinsic cardiac output on gradual daily reduction of support flow ( fig .  1 )
moreover , spontaneous respiration was carefully monitored by pulse oximetry and repeated blood gas analyses , while pulmonary oedema was aggressively treated by combined diuretic therapy ( fig .  1 ) .
this strategy seems imperative as , for example , pneumonia may render va - ecmo without intubation impossible .
others have reported on awake va - ecmo requiring additional percutaneous atrioseptostomy to treat pulmonary congestion , which was not necessary in our patient .
moreover , neurological performance remained unremarkable and could easily be evaluated in this cooperative patient .
neurological assessment is of utmost importance during peripheral va - ecmo , especially on recovering cardiac function and pending pulmonary oedema , which might cause hypoxaemia of the proximal aortic arch , that is , the harlequin syndrome . after roughly a week of va - ecmo support ,
cardiac recovery was accompanied by immediate physical mobilisation creating optimal conditions for the subsequent clinical course .
va - ecmo for severe and refractory cardiogenic shock may successfully be performed without mechanical ventilation .
careful monitoring of volume status and respiratory condition is imperative and allows keeping patients comfortable and cooperative also during prolonged periods of extracorporeal support .
the limited invasiveness of this stand - alone va - ecmo approach may encourage a more widespread and accessible use in cardiogenic shock .
 we report on the use of percutaneous femoral veno - arterial extracorporeal membrane oxygenation ( va - ecmo ) in a fully awake , non - intubated and spontaneously breathing patient suffering from acute , severe and refractory cardiogenic shock due to a ( sub)acute anterior myocardial infarction . intensified heart failure therapy was closely monitored with a pulmonary artery catheter and allowed gradual weaning off the ecmo support without additional invasive measures , notably without mechanical ventilation . 
 neurological assessment was possible at all times and complete physical mobilisation was straightforward directly after weaning from ecmo . this limited invasive approach may encourage a more widespread use of percutaneous va - ecmo . 
Introduction
Discussion
Conclusion