Conclusion
Given the increase in the number of heart transplants off of VA-ECMO, there is a need for strategies that allow for patient optimization without further deconditioning.  In fact, a protocolized approach by Coutance and colleagues resulted in equivalent outcomes between patients undergoing transplant with and without pre-transplant ECMO5.  Not surprisingly, patients that had not finished transplant listing prior to ECMO support had a longer duration of ECMO prior to transplantation (chronic heart failure listed patients (5-8 days) versus new onset heart failure (12 days)). This suggests a longer period for optimization in new onset heart failure patients who are new to a system and have not finished up transplant candidacy decision or have acute end organ dysfunction that needs to be temporized. We present a novel approach to ambulatory VA-ECMO with extra-pericardial aortic, via upper mini sternotomy, and venous cannulation in the internal jugular vein.   Our patient had a BMI of 20 kg/m2 with small stature and an axillary artery that was 5 mm in size.  Vascular complications following ECMO is the most common cause of death with axillary cannulation strategy resulting in limb hyperemia in 15% of cases6 and femoral cannulation in up to 20% cases.   Anterior thoracotomy with aortic and right atrial cannulation is a viable strategy but can result in bleeding into pericardium leading to tamponade physiology. We present a novel strategy for VA-ECMO cannulation with central aortic cannulation above the pericardial reflection to avoid violating the pericardium.  This mitigates the risk of bleeding into the pericardium and causing tamponade, especially on anticoagulation. Secondly, venous drainage in the right IJ allows greater mobility by leaving both groins free of cannulas. These advantages make this a viable approach for patients who require VA ECMO.