Review

. 2024 Dec;50(12):1994-2004.

doi: 10.1007/s00134-024-07645-8. Epub 2024 Nov 18.

Position paper on the physiology and nomenclature of dual circulation during venoarterial ECMO in adults

Jenelle Badulak^#^{1

2

3}, Darryl Abrams^#⁴, Andrew M Luks⁵, Bishoy Zakhary⁶, Steven A Conrad⁷, Robert Bartlett⁸, Graeme MacLaren⁹, Leen Vercaemst¹⁰, Roberto Lorusso¹¹, Lars Mikael Broman^{12

13}, Cara Agerstrand⁴, Susanna Price^{14

15}, Alain Combes¹⁶, Giles Peek¹⁷, Eddy Fan¹⁸, Kiran Shekar¹⁹, John Fraser¹⁹, Daniel Brodie²⁰; Extracorporeal Life Support Organization (ELSO)

Affiliations

¹ Department of Emergency Medicine, University of Washington, Seattle, WA, USA. badulakj@uw.edu.
² Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA. badulakj@uw.edu.
³ Division of Cardiothoracic Surgery, University of Washington, Seattle, WA, USA. badulakj@uw.edu.
⁴ Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
⁵ Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
⁶ Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA.
⁷ Departments of Medicine, Emergency Medicine, Pediatrics and Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA.
⁸ Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
⁹ Cardiothoracic ICU, National University Hospital, Singapore, Singapore.
¹⁰ University Hospital Gasthuisberg, Louvain, Belgium.
¹¹ Cardiothoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, Netherlands.
¹² ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden.
¹³ Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
¹⁴ Royal Brompton Hospital, London, UK.
¹⁵ National Heart and Lung Institute, Imperial College, London, UK.
¹⁶ Department of Intensive Care Medicine, Sorbonne University, La Pitie-Salpetriere Hospital, Paris, France.
¹⁷ Division of Cardiothoracic Surgery, University of Florida Shands Children's Hospital, Congenital Heart Center at University of Florida Health, Gainesville, FL, USA.
¹⁸ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
¹⁹ Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia.
²⁰ Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

^# Contributed equally.

PMID: 39557688
PMCID: PMC11588769
DOI: 10.1007/s00134-024-07645-8

Review

Position paper on the physiology and nomenclature of dual circulation during venoarterial ECMO in adults

Jenelle Badulak et al. Intensive Care Med. 2024 Dec.

. 2024 Dec;50(12):1994-2004.

doi: 10.1007/s00134-024-07645-8. Epub 2024 Nov 18.

Authors

Affiliations

¹ Department of Emergency Medicine, University of Washington, Seattle, WA, USA. badulakj@uw.edu.
² Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA. badulakj@uw.edu.
³ Division of Cardiothoracic Surgery, University of Washington, Seattle, WA, USA. badulakj@uw.edu.
⁴ Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
⁵ Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
⁶ Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR, USA.
⁷ Departments of Medicine, Emergency Medicine, Pediatrics and Surgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, USA.
⁸ Department of Surgery, University of Michigan, Ann Arbor, MI, USA.
⁹ Cardiothoracic ICU, National University Hospital, Singapore, Singapore.
¹⁰ University Hospital Gasthuisberg, Louvain, Belgium.
¹¹ Cardiothoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, Netherlands.
¹² ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden.
¹³ Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.
¹⁴ Royal Brompton Hospital, London, UK.
¹⁵ National Heart and Lung Institute, Imperial College, London, UK.
¹⁶ Department of Intensive Care Medicine, Sorbonne University, La Pitie-Salpetriere Hospital, Paris, France.
¹⁷ Division of Cardiothoracic Surgery, University of Florida Shands Children's Hospital, Congenital Heart Center at University of Florida Health, Gainesville, FL, USA.
¹⁸ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
¹⁹ Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia.
²⁰ Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

^# Contributed equally.

PMID: 39557688
PMCID: PMC11588769
DOI: 10.1007/s00134-024-07645-8

Erratum in

Correction: Position paper on the physiology and nomenclature of dual circulation during venoarterial ECMO in adults.
Badulak J, Abrams D, Luks AM, Zakhary B, Conrad SA, Bartlett R, MacLaren G, Vercaemst L, Lorusso R, Broman LM, Agerstrand C, Price S, Combes A, Peek G, Fan E, Shekar K, Fraser J, Brodie D; Extracorporeal Life Support Organization (ELSO). Badulak J, et al. Intensive Care Med. 2025 Mar;51(3):661-662. doi: 10.1007/s00134-025-07809-0. Intensive Care Med. 2025. PMID: 39937222 Free PMC article. No abstract available.

Abstract

When native blood flow through the aorta from the adult heart and lungs meets retrograde blood flow from an artificial heart and lung during venoarterial extracorporeal membrane oxygenation (VA-ECMO), the result is the creation of two separate circulations on either side of the blood flow mixing point. This phenomenon is known as dual circulation and is characterized by different content of oxygen and carbon dioxide between the circulations. There is currently a lack of clarity surrounding the nomenclature to describe this physiologic phenomenon in VA-ECMO and thus we endeavor to name and define these terms to facilitate clear communication and proper clinical management of these patients.

Keywords: Differential carbon dioxide; Differential oxygenation; Dual circulation; Extracorporeal life support; Extracorporeal membrane oxygenation; Mixing point.

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Conflict of interest statement

Declarations. Conflicts of interest: JB is the immediate past chair of the Extracorporeal Life Support Organization (ELSO) Nominations and Membership Committee and a member of the ELSO Education Committee. DB received research support from and consults for LivaNova. He has been on the medical advisory boards for Xenios, Medtronic, Inspira and Cellenkos. He is the President-elect of the ELSO and the Chair of the Executive Committee of the International ECMO Network (ECMONet), and he writes for UpToDate. RB serves on the ELSO Board of Directors. AC receives research funding and personal fees from Getinge, Baxter, and Xenios. RL is a consultant for Medtronic, LivaNova, Xenios and Eurosets, receives personal fees from Abiomed, received research grants from Medtronic and LivaNova, and he is the chair of the ELSO Research Committee. KS receives research support from Queeensland Health and is a member of the Scientific Committee of ECMONet, and Education and Guidelines committees of ELSO. GMacL is the president of ELSO. BZ is the immediate past chair of the ELSO Education Committee. CA writes for UpToDate, and is the immediate past chair of the ELSO Conference Committee. EF reports personal fees from ALung Technologies, Baxter, Getinge, Inspire, Vasomune, and Zoll Medical outside the submitted work, and is the immediate past chair of the ELSO Research Committee. JF has received grants from Xenios, Mera, Fischer and Paykel, and he is co-founder BiVACOR total artificial hearts. LMB is a consultant for Xenios/Fresenius, Eurosets, and HemoCue, and member of EuroELSO Scientific Committee. The remaining authors declare no conflicts of interest and have no financial disclosures. There was no financial support for this study.

Figures

**Fig. 1**
Competitive flows and mixing point in peripheral VA-ECMO. a Mixing point (arrows) located in the proximal aorta due to a high ratio of ECMO blood flow to cardiac output. b Mixing point (arrows) in the descending thoracic aorta due to a decreased ratio of ECMO blood flow to cardiac output. *ECMO* extracorporeal membrane oxygenation. Image used with permission from Columbia University Irving Medical Center

**Fig. 2**
Illustration describing an example of the approximate anatomic location corresponding to key terms used for dual circulation in VA-ECMO. Image used with permission from Abigail R. Liberty, MS, CMI

**Fig. 3**
Hybrid V-AV ECMO cannula configuration with drainage cannula in the femoral vein and return cannulas in the femoral artery and internal jugular vein. Image used with permission from Columbia University Irving Medical Center

See this image and copyright information in PMC

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References

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Position paper on the physiology and nomenclature of dual circulation during venoarterial ECMO in adults

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Position paper on the physiology and nomenclature of dual circulation during venoarterial ECMO in adults

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