Weaning from VA-ECMO remains a challenging but critically important step in device management. The key is to balance minimizing complications associated with device support with the potential for hemodynamic deterioration if support is prematurely discontinued.

We advocate for a standardized and systematic approach to weaning but also recognize that deviation from the above approach may be required in specific clinical scenarios.

When a patient has tolerated a trial of 2 LPM of blood flow for a minimum of 8h with stable hemodynamics and end-organ function and tolerates transient flow reduction to 1 LPM at the bedside, the patient is typically taken to the operating room for ECMO decannulation.

The final assessment is performed at this time, wherein blood flows are gradually decreased and the cannulae are clamped; hemodynamic and ABG parameters are checked.

Focused echocardiography is often undertaken to assess the impact of flow reduction on biventricular function. If acceptable, decannulation is performed.

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