The Forgotten Right Ventricle: A Major Player in Successful VA-ECMO Weaning and Survival, Results from a Standardized Three-Step Protocol

All articles of this category (opens in new window) Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as the cornerstone of mechanical circulatory support for patients with refractory cardiogenic shock. This study aims to evaluate the efficacy of a three-step weaning protocol and systematically identify hemodynamic predictors of successful weaning, with particular emphasis on right ventricular function and pulmonary vascular resistance. Methods: This single-center retrospective analysis included 39 consecutive patients with severe cardiogenic shock requiring VA-ECMO. Our standardized three-step weaning protocol was systematically initiated 5 to 7 days following extracorporeal support implantation. The protocol consisted of three sequential phases: Phase 1 evaluation and invasive hemodynamic monitoring during complete cardiac decompression. Phase 2 involved systematic reduction of extracorporeal flow to 1 L/minutes. Phase 3 comprised a temporary cessation of extracorporeal support for 10 minutes with intensive monitoring of hemodynamic parameters. The primary endpoint was defined as successful weaning from extracorporeal support with survival to hospital discharge. Secondary endpoints included 30-day survival and identification of hemodynamic predictors associated with successful weaning. Results: A total of 66.7% were successfully weaned and survived to hospital discharge, while 33.3% died following weaning attempts. The 30-day survival rate was 66.7%. Mean pulmonary arterial pressure was significantly lower in survivors compared to nonsurvivors (26.5 ± 7.4 mmHg vs. 35.2 ± 6.2 mmHg, representing a 33% difference). Similarly, pulmonary capillary wedge pressure demonstrated substantial differences between groups (15.8 ± 5.8 mmHg in survivors vs. 25.0 ± 9.4 mmHg in nonsurvivors, reflecting a 58% increase in the nonsurvivor group). Primary causes of mortality following weaning included cerebral hemorrhage in five patients (38.5% of deaths), multi-organ failure in six patients (46.2% of deaths), and recurrent cardio-genic shock in two patients (15.4% of deaths). Conclusion: Right ventricular dysfunction, manifested through elevated pulmonary arterial pressures and increased pulmonary capillary wedge pressures, served as the primary determinant of weaning failure. These findings suggest that right heart assessment should be elevated to equal importance with left ventricular evaluation in weaning protocols. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany