Recurrent or prolonged mechanical circulatory support: bridge to recovery or road to nowhere?

Remarkable outcomes have been reported after prolonged mechanical circulatory support in the pediatric population, but there is yet no clear delineation of the duration beyond which supporting a child becomes futile. The likelihood of survival in patients supported on extracorporeal membrane oxygenation for respiratory failure decreases with the length of support. However, extracorporeal membrane oxygenation can be successfully used in these patients for long periods (weeks to months) provided adequate support is maintained without complications. This is not the case with cardiac failure and mechanical circulatory support.Extracorporeal membrane oxygenation is usually the initial form of mechanical circulatory support used in patients with primary refractory myocardial dysfunction. There is evidence and consensus that if the patient shows no signs of recovery after a maximum duration of 2 weeks, he or she should be transitioned to a ventricular assist device, which allows prolonged support. In post-cardiac surgery patients, survival is only anecdotal beyond 12 days of extracorporeal membrane oxygenation support, and myocardial recovery is exceptionally rare after this time period unless new diagnoses and management strategies are formulated.Repeat extracorporeal membrane oxygenation should generally not be offered to patients unless it is established that support was withdrawn prematurely or a new intervention is planned. Repeat extracorporeal membrane oxygenation may achieve some improvement in early survival, but the long-term outcomes of survivors are so poor that these attempts cannot be generally recommended unless organ transplantation is an option.