A Vanderbilt case report describes parallel VV–VA ECMO with axillary Impella 5.5 as a bridge to heart–lung transplantation in a 65-year-old man with severe cardiac and pulmonary failure. Separate circuits supported gas exchange and circulation, while Impella unloaded the left ventricle. He remained awake and extubated for 60 hours before transplantation. Recovery included a femoral artery pseudoaneurysm requiring repair; one successful case cannot establish comparative safety or effectiveness.
Supporting Failing Heart and Lung Function
Patients awaiting combined heart–lung transplantation may need respiratory support, circulatory support, and left ventricular decompression at the same time. In this report, Enock Adjei and colleagues at Vanderbilt University Medical Center describe an individualized peripheral platform combining two independent ECMO circuits with an axillary Impella 5.5. The approach was used after a single hybrid circuit no longer met the patient’s needs. It illustrates how separate devices can address distinct physiologic problems while maintaining an awake, extubated bridge to transplantation.
The underlying challenge is that each support configuration has limitations. Veno-venous ECMO provides gas exchange but does not directly support systemic circulation. Veno-arterial ECMO supports circulation and oxygen delivery, but its effect on left ventricular afterload may worsen ventricular distension. A hybrid V-AV circuit can provide both venous and arterial return, yet the flow distribution remains coupled within one circuit. In this patient, the team ultimately separated respiratory and circulatory support and added active ventricular unloading.
Initial Stabilization and Subsequent Deterioration
The patient was a 65-year-old man with nonischemic cardiomyopathy, a left ventricular ejection fraction below 10%, and COVID-19-associated pulmonary fibrosis diagnosed four months earlier. Although he required supplemental oxygen at rest, he reportedly walked approximately four miles daily before admission. He presented with cardiogenic shock and refractory respiratory acidosis despite maximal ventilatory support. His initial pH was 7.11 and PaCO₂ was 97 mmHg. A brief ventricular arrhythmic arrest required two minutes of cardiopulmonary resuscitation.
Urgent V-AV ECMO was initiated using right femoral venous drainage, right internal jugular venous return, and right femoral arterial return with distal limb perfusion. This stabilized the patient sufficiently to discontinue vasopressors and extubate him. On hospital day two, he stood at the bedside and walked within his room while undergoing expedited transplant evaluation. He was approved for transplantation as Status 1.
By hospital day three, progressive hypoxemia and acute kidney injury developed despite maximal hybrid support. Oxygen saturation fell to 75%–80% during routine repositioning. The V-AV circuit delivered a total flow of 6.5 L/min, divided into 4.0 L/min of venous return and 2.5 L/min of arterial return. High-flow nasal oxygen was also required. Imaging showed near-complete bilateral pulmonary opacification, and pulmonary artery pressure was 73/40 mmHg, with a mean of 51 mmHg, despite inhaled nitric oxide.
Parallel VV–VA ECMO and Active LV Unloading
The team reconfigured support into two peripheral circuits. The VV circuit used a 25-Fr right femoral venous drainage cannula and a 21-Fr right internal jugular return cannula. The VA circuit used a 23-Fr left femoral venous drainage cannula and a 15-Fr right common femoral arterial return cannula with a distal perfusion catheter. This arrangement allowed respiratory and circulatory flows to be adjusted independently rather than sharing the output of one pump.
During reconfiguration, echocardiography showed progressive left ventricular distension, reduced systemic pulsatility below 10 mmHg, and moderate mitral regurgitation. These findings prompted placement of a right axillary Impella 5.5 for active ventricular decompression. The reported operating flows were approximately 5 L/min for VV ECMO, 3 L/min for VA ECMO, and 2.0–2.2 L/min from Impella at P3–P4. These values describe this individual case and should not be interpreted as a validated protocol or simply added together as effective systemic blood flow.
The patient remained awake, extubated, and hemodynamically stable on the combined platform for approximately 60 hours before transplantation. He participated in bed-based rehabilitation during this phase. This distinction matters: the earlier room ambulation occurred during initial V-AV support, while the report describes bed rehabilitation after escalation to the triple-device configuration.
Transplantation, Recovery, and Vascular Complications
A donor became available on hospital day five, and the patient underwent en-bloc heart–lung transplantation through a clamshell incision. Postimplantation echocardiography showed normal biventricular function with an ejection fraction above 65%. Lung mechanics and oxygenation were satisfactory, and postoperative mechanical circulatory support was not required. A tracheostomy was performed on postoperative day two to assist ventilator weaning. Vasopressors and inotropes were discontinued by postoperative day three.
Recovery nevertheless involved substantial postoperative care. The patient spent 14 days in intensive care while receiving continuous renal replacement therapy. On postoperative day 30, he developed a right groin hematoma and a 4-mm common femoral artery pseudoaneurysm at the previous VA-ECMO cannulation site. Operative exploration and primary arterial repair were required, followed by two weeks of wound vacuum therapy. He was discharged to inpatient rehabilitation on day 45 and returned home one week later.
At three months, he was performing daily activities independently. Echocardiography showed an ejection fraction of 55%–65%, and pulmonary testing showed an FEV₁ of 2.98 L and FVC of 97% predicted. The authors reported no clinical or biopsy evidence of rejection. The favorable recovery is meaningful, but the vascular complication demonstrates that avoiding central cannulation does not eliminate the hazards of multisite peripheral access.
Implications for Perfusion Practice
The case highlights the value of assessing gas exchange, systemic perfusion, and ventricular loading as related but distinct support targets. Serial echocardiography identified deterioration in ventricular loading despite extracorporeal circulatory support. Independent circuits provided additional flexibility, while axillary Impella support addressed left ventricular distension. The authors also discuss alternative configurations, including axillary arterial ECMO return, and explain the procedural and physiologic reasons for their selection in this patient.
For perfusion teams, the practical lessons concern reassessment and coordination rather than adoption of a universal configuration. Multiple devices require careful management of drainage, flow balance, oxygenation, ventricular filling, limb perfusion, and vascular access. The authors emphasize surveillance and decannulation management after the delayed femoral complication. They also suggest that strong premorbid functional capacity can be relevant to candidate selection, although this report cannot establish age-related selection criteria.
Evidence Limitations
This is a single-patient case report without a comparison group, standardized treatment assignment, or long-term follow-up beyond the reported recovery period. It demonstrates feasibility at a highly experienced center, not superiority over other ECMO or unloading strategies. The contribution of each device cannot be separated from transplant timing, patient selection, and multidisciplinary care. Larger studies are needed to define which candidates may benefit and to characterize bleeding, vascular, and other device-related risks.
Attribution: © 2026 The Authors. Published under CC BY 4.0. This independently written IPA summary accompanies the source article. Cover artwork is conceptual.
Original Article
Adjei E, Teimouri Dereshgi A, McGann KC, et al. Maximizing cardiopulmonary support as a minimally invasive platform—using peripheral parallel veno-venous and veno-arterial extracorporeal membrane oxygenation and axillary Impella 5.5 as a bridge to heart–lung transplantation. JHLT Open. 2026;14:100684. Read the original article.
