European Journal of Cardiovascular Medicine

Extracorporeal membrane oxygenation (ECMO) has become an indispensable life-support modality for patients with refractory cardiac and/or respiratory failure who fail to respond to maximal conventional therapy. Advances in ECMO circuit design, oxygenator efficiency, anticoagulation strategies, and multidisciplinary team training have significantly expanded its application in adult critical care. Data from the Extracorporeal Life Support Organization (ELSO) registry indicate that more than 190,000 ECMO runs have been reported globally, with adult ECMO accounting for over 60% of total utilization. Survival to hospital discharge remains approximately 55–60% for veno-venous (VV) ECMO in severe acute respiratory distress syndrome (ARDS) and 40–45% for veno-arterial (VA) ECMO in cardiogenic shock [1,2].

ECMO configurations are broadly categorized into VV ECMO for isolated respiratory failure and VA ECMO for circulatory failure with or without concomitant respiratory compromise. However, contemporary critical care practice increasingly recognizes ECMO as a dynamic support strategy, where transitions between modalities may be required as the underlying pathophysiology evolves. VA-to-VV ECMO conversion has gained prominence in patients who initially present with profound shock requiring circulatory support but later demonstrate myocardial recovery with persistent severe lung injury. Such adaptive ECMO strategies reflect real-world critical care complexity rather than rigid adherence to single-modality support.

In India, ECMO utilization has expanded rapidly over the last decade, particularly in tertiary and quaternary care centers. Indian ECMO Registry and multicenter observational studies report an annual rise in adult ECMO cases, with VV ECMO accounting for approximately 60–65% and VA ECMO for 30–35% of total adult ECMO runs [3,4]. Reported survival rates from Indian centers range between 50–65% for VV ECMO in severe ARDS and 30–50% for VA ECMO in cardiogenic shock, depending on etiology, timing of initiation, and presence of multi-organ dysfunction [4–6]. Common Indian indications include severe viral and bacterial ARDS, septic shock with myocardial depression, post-cardiotomy shock, and toxicological emergencies.

From a regional perspective, Gujarat—particularly South and Central Gujarat—has emerged as an important ECMO hub, owing to the presence of high-volume cardiac and critical care centers in cities such asSurat, Ahmedabad, Vadodara, and Vapi. Published case series and institutional reports from Gujarat highlight frequent ECMO use in aluminum phosphide poisoning, a toxicological emergency endemic to western India, as well as in severe sepsis, dengue shock syndrome, and ARDS [7–9]. Survival rates in aluminum phosphide poisoning supported with VA ECMO have been reported between 25–40%, which, although modest, represent a significant improvement compared to near-universal mortality with conventional therapy alone [7,8].

Clinical data from high-volume ICUs in South Gujarat further demonstrate that ECMO utilization often involves sequential or hybrid modality use rather than isolated VA or VV support. The uploaded institutional data illustrate scenarios where patients with dengue-associated septic shock with ARDS were initially stabilized using VA-V ECMO, followed by arterial cannula removal and conversion to VV ECMO after hemodynamic recovery, while respiratory failure persisted. Similarly, in aluminum phosphide poisoning, patients frequently required VA ECMO for refractory cardiogenic shock and were later transitioned to VV ECMO due to secondary sepsis and ARDS. These patterns underscore the multisystem nature of critical illness in tropical and toxicological conditions, which are particularly prevalent in South Gujarat and surrounding regions.

Despite increasing ECMO adoption in India and Gujarat, there remains a paucity of consolidated data examining utilization patterns, ECMO modality transitions, and outcome determinants within a single high-volume center. Most available studies focus on disease-specific outcomes or single ECMO configurations, leaving an important evidence gap regarding real-world ECMO practice in Indian ICUs. Understanding these utilization trends is essential not only for optimizing patient outcomes but also for guiding ethical decision-making, cost-effectiveness considerations, and protocol development in resource-constrained settings.

Therefore, this study aims to analyze the utilization patterns and clinical outcomes of ECMO modalities in a high-volume Indian critical care unit. By evaluating indications, ECMO configurations (VA, VV, and modality transitions), and associated outcomes, this study seeks to provide regionally relevant evidence to inform ECMO practice in India, with particular applicability to South Gujarat and similar high-acuity critical care environments.

This multicentric hospital-based observational study was conducted across high-volume tertiary care critical care units in South Gujarat, India, including Universal Super Speciality Hospital, Surat, over a 9-year period from January 2017 to December 2025. These centers have established adult extracorporeal membrane oxygenation (ECMO) programs with round-the-clock availability of trained intensivists, cardiothoracic surgical support, perfusionists, and dedicated critical care nursing staff. The study was designed to evaluate real-world utilization patterns and clinical outcomes of different ECMO modalities in adult patients managed in a high-acuity Indian critical care setting. All adult patients aged 18 years and above who received ECMO support during the study period were included using a consecutive sampling method to avoid selection bias. A total of 200 patients were enrolled in the final analysis. Patients were included if ECMO was initiated for aluminum phosphide poisoning with refractory cardiogenic shock, severe acute respiratory distress syndrome (ARDS) of viral or non-viral etiology, or combined cardiopulmonary failure. Patients younger than 18 years, those who expired before ECMO initiation, patients with irreversible neurological injury prior to ECMO, and those with terminal illness or end-stage organ failure not amenable to recovery were excluded from the study. The decision to initiate ECMO and selection of ECMO modality were made by a multidisciplinary ECMO team based on clinical assessment, hemodynamic parameters, laboratory findings, and imaging studies. Veno-arterial (VA) ECMO was primarily used in patients with aluminum phosphide poisoning presenting with profound cardiogenic shock, particularly when ECMO could be initiated early, within 4–6 hours of poison ingestion. Veno-venous (VV) ECMO was predominantly employed in patients with severe ARDS, including viral pneumonia, COVID-19–associated ARDS, and selected tropical ARDS cases. Hybrid or transition ECMO modalities (veno-arteriovenous or modality transition) were used rarely and only when clinically unavoidable. All patients were managed according to standardized institutional ECMO protocols. Cannulation strategy, ventilatory management, anticoagulation, and hemodynamic targets were individualized based on patient condition and underlying pathology. VA ECMO runs were generally short, typically lasting 4–6 days, reflecting early myocardial recovery in toxin-induced cardiogenic shock. In contrast, VV ECMO support was prolonged, with duration ranging from a minimum of 3 weeks up to 8 weeks, depending on lung recovery and resolution of respiratory failure. Daily multidisciplinary assessments were conducted to monitor organ function, ECMO-related complications, and readiness for weaning and decannulation. Data were collected retrospectively from intensive care unit records, ECMO run sheets, and electronic medical records using a structured data collection proforma. Variables recorded included demographic characteristics, primary diagnosis and indication for ECMO, ECMO modality used, timing of ECMO initiation (with special emphasis on ingestion-to-ECMO interval in aluminum phosphide poisoning), duration of ECMO support, ECMO-related complications such as sepsis, bleeding, acute kidney injury requiring renal replacement therapy, limb ischemia, and neurological events, successful decannulation, length of ICU stay, and survival status at hospital discharge. The primary outcome measure was survival to hospital discharge. Secondary outcomes included successful ECMO decannulation, duration of ECMO support by modality, complication profile, and length of intensive care unit stay. Ethical approval for the study was obtained from the Institutional Ethics Committees of the participating centers. Patient confidentiality was strictly maintained, and the study was conducted in accordance with the principles of the Declaration of Helsinki. All data were entered into Microsoft Excel and analyzed using SPSS software. Categorical variables were expressed as frequencies and percentages, while continuous variables were summarized using mean with standard deviation or median with range, as appropriate. Statistical significance was considered at a p-value of less than 0.05.

During the 9-year study period from January 2017 to December 2025, a total of 200 adult patients received extracorporeal membrane oxygenation (ECMO) support across the participating high-volume critical care centers. The majority of patients were in the 41–60-year age group (92; 46.0%), followed by those aged ≤40 years (76; 38.0%), while 32 patients (16.0%) were older than 60 years. There was a marked male predominance (142; 71.0%), reflecting the demographic profile commonly observed in toxicological emergencies and severe critical illness in India.

Aluminum phosphide poisoning was the most common primary diagnosis, accounting for 110 patients (55.0%), followed by ARDS due to viral pneumonia including COVID-19 (58; 29.0%), non-viral/tropical ARDS including dengue (20; 10.0%), and non-toxicological cardiogenic shock (12; 6.0%). Correspondingly, cardiac failure was the predominant physiological indication for ECMO (122; 61.0%), while respiratory failure accounted for 78 patients (39.0%). This distribution reflects early presentation with profound cardiogenic shock in aluminum phosphide poisoning and severe hypoxemic respiratory failure in ARDS patients.

With respect to ECMO modality utilization, initial veno-arterial (VA) ECMO was initiated in 122 patients (61.0%), while initial veno-venous (VV) ECMO was used in 78 patients (39.0%). A VA-V configuration during the ECMO run was required in 2 patients (1.0%) (subset of VA ECMO cases), and both patients died during hospitalization; hence, this configuration was not analyzed separately. VA ECMO runs were relatively short (4–6 days), reflecting rapid myocardial recovery in toxin-induced cardiogenic shock, whereas VV ECMO support was prolonged, ranging from 3 weeks to up to 2 months, depending on lung recovery.

Overall, 98 patients (49.0%) survived to hospital discharge, while 102 patients (51.0%) died during hospitalization. ECMO decannulation was achieved in 102 patients (51.0%); of these, 98 patients survived to hospital discharge, while 4 patients died after successful decannulation during the same hospitalization due to ongoing critical illness. When outcomes were analyzed by ECMO modality, VA ECMO demonstrated better survival, with 67 of 122 patients (55.0%) surviving, compared to 31 of 78 patients (40.0%) supported with VV ECMO. Both patients who required VA-V configuration expired, resulting in 100% mortality in this small subgroup.

Inter-hospital transport ECMO was performed in five patients on VV ECMO support; among them, one patient survived to hospital discharge, while four patients died during hospitalization, indicating high mortality associated with transport ECMO in critically ill respiratory failure patients.

Among patients with aluminum phosphide poisoning, all of whom required VA ECMO for severe cardiogenic shock, 61 of 110 patients (55.0%) survived to hospital discharge. Survival was notably better when VA ECMO was initiated within 4–6 hours of poison ingestion, supporting ECMO as an effective bridge to toxin clearance and myocardial recovery. In contrast, VV ECMO outcomes were less favorable, particularly in patients with viral pneumonia and COVID-19–associated ARDS. During the 2020–2023 COVID period, VV ECMO survival declined to 22.0%, whereas patients with non-viral or tropical ARDS demonstrated comparatively better outcomes.

ECMO-related complications were observed predominantly among patients requiring prolonged VV ECMO support. Sepsis or bloodstream infection occurred in 64 patients (32.0%), acute kidney injury requiring renal replacement therapy in 56 patients (28.0%), and major bleeding in 4 patients (2.0%). Limb ischemia; all were VA ECMO patients (5; 2.5%, among them 2 patients needed amputation) and neurological complications (6; 3.0%) were less frequent. Complication-related mortality was primarily confined to prolonged VV ECMO runs, whereas VA ECMO patients demonstrated comparatively lower mortality, despite presenting with severe cardiogenic shock, due to early initiation and shorter ECMO duration.

Overall, the results demonstrate that timely VA ECMO initiation in aluminum phosphide poisoning is associated with favorable survival despite severe hemodynamic compromise, while VV ECMO, although beneficial in severe ARDS, requires prolonged support and is associated with higher mortality, particularly in viral pneumonia cohorts. These findings underscore the importance of early referral, appropriate modality selection, and etiology-driven ECMO strategies in optimizing outcomes in Indian critical care practice.

Table 1. Baseline Clinical Profile and Indications for ECMO (n = 200)

Table 2. ECMO Utilization Patterns and Modality Distribution (n = 200)

Figure 1: Distribution of ECMO Indications (%)

Table 3. Clinical Outcomes and ECMO-Related Complications (n = 200) \

Interpretation (updated): ECMO decannulation was achieved in 102 patients (51.0%). Survival to hospital discharge was 49.0%, and 2.0% of patients died after decannulation during the same hospitalization. VA ECMO showed higher survival than VV ECMO.

Table 4. Predictors of Survival to Hospital Discharge (Multivariable Analysis)

Figure 2: ECMO Related Complications

Figure 3: Predictors of Survival to Hospital Discharge (Forest Plot)

This multicentric 9-year observational study provides important real-world insights into extracorporeal membrane oxygenation (ECMO) utilization and outcomes in high-volume Indian critical care units. The principal finding of this study is that veno-arterial (VA) ECMO demonstrated better survival than veno-venous (VV) ECMO, a result that contrasts with many Western ECMO registries but is strongly explained by the predominance of aluminum phosphide (ALP) poisoning and the practice of early ECMO initiation in this cohort.

VA ECMO in Aluminum Phosphide Poisoning: Role of Early Initiation

Aluminum phosphide poisoning constituted 55% of all ECMO cases in this study, making it the single most important indication. ALP poisoning leads to rapid onset of severe cardiogenic shock due to reversible myocardial depression, severe metabolic acidosis, and circulatory collapse. In the absence of mechanical circulatory support, mortality is extremely high. In the present study, VA ECMO survival in ALP poisoning was 55%, which is substantially higher than historical outcomes reported with conservative management alone and comparable to outcomes reported in selected Indian series where ECMO was initiated early [10–12].

The most critical determinant of survival in ALP poisoning in this study was timely VA ECMO initiation within 4–6 hours of ingestion, supporting the concept of ECMO as a bridge to toxin clearance and myocardial recovery rather than as a late salvage therapy. Prior Indian studies have consistently shown that delayed initiation of ECMO in ALP poisoning is associated with poor outcomes, whereas early circulatory support significantly improves survival despite severe initial shock [11,13]. The short VA ECMO duration (4–6 days) observed in this cohort further supports the reversibility of myocardial dysfunction in ALP poisoning when early support is provided.

VV ECMO in ARDS: Prolonged Runs and Higher Mortality

VV ECMO was primarily utilized for severe ARDS, including viral pneumonia, COVID-19–associated ARDS, and selected tropical ARDS cases such as dengue. In contrast to VA ECMO, VV ECMO runs were markedly prolonged, ranging from 3 weeks to up to 2 months, reflecting slow lung recovery and ongoing inflammatory injury. Overall VV ECMO survival in this study was 40%, which was lower than VA ECMO survival and lower than outcomes reported in some international ARDS-focused VV ECMO cohorts [14,15].

A particularly important observation was the poor VV ECMO survival during the COVID-19 period (2021–2023), where survival declined to 22%. Similar reductions in VV ECMO outcomes during COVID-19 have been reported globally and in India, attributed to delayed referral, prolonged mechanical ventilation prior to ECMO initiation, secondary infections, and severe fibrotic lung injury [16–18]. In contrast, patients with non-viral or tropical ARDSdemonstrated relatively better outcomes, highlighting that etiology plays a crucial role in VV ECMO success.

An additional high-risk subgroup in this study was patients requiring inter-hospital transport on VV ECMO support. Among the five transported patients, only one survived to hospital discharge, highlighting the substantial logistical and physiological challenges associated with transport ECMO in severe respiratory failure. Factors such as delayed initiation, hemodynamic instability during transfer, prolonged pre-ECMO ventilation, and limited transport infrastructure likely contributed to poor outcomes. These findings emphasize that transport ECMO should be reserved for carefully selected patients and performed by experienced teams.

Duration of ECMO and Complication Burden

The difference in outcomes between VA and VV ECMO in this study is closely linked to duration of support and cumulative complication burden. VA ECMO patients, despite presenting with severe cardiogenic shock, required short ECMO runs and experienced fewer prolonged complications. Conversely, prolonged VV ECMO runs were associated with higher rates of sepsis, acute kidney injury requiring renal replacement therapy, and major bleeding, which were the primary contributors to mortality. Large registry analyses have similarly demonstrated that prolonged ECMO duration increases the risk of infectious and hemorrhagic complications and is independently associated with mortality [19,20].

Limited Role of Hybrid or Transition ECMO

Hybrid or transition ECMO (VA-V or modality transition) was used in only two patients in this cohort, and both patients died. Given the extremely low utilization and uniformly poor outcomes, hybrid ECMO did not play a meaningful role in outcome determination in this study. While Western literature reports higher rates of ECMO modality transitions in dynamic critical illness, Indian ECMO practice appears to emphasize early correct modality selection rather than later escalation, particularly in resource-intensive settings [21].

Overall Outcomes in Indian Context

Despite the high acuity of illness and inclusion of severe toxicological and respiratory failure cases, approximately half of the patients (49%) survived to hospital discharge, while overall in-hospital mortality was 51%.Despite the high acuity of illness and inclusion of severe toxicological and respiratory failure cases, approximately half of the patients (49%) survived to hospital discharge, while overall in-hospital mortality was 51%. Importantly, ECMO decannulation was achieved in slightly more than half of the cohort; however, a small proportion of patients (2%) died after successful decannulation due to persistent multiorgan dysfunction and secondary complications. Mortality was predominantly observed in the VV ECMO group, particularly among patients requiring prolonged support and those who developed major infectious, renal, or bleeding complications. These findings differ from Western registries, where VA ECMO often carries higher mortality, underscoring the importance of context-specific disease patterns in interpreting ECMO outcomes [22].

Clinical Implications

The findings of this study have important implications for ECMO practice in India. First, early VA ECMO should be strongly considered in aluminum phosphide poisoning, even in patients presenting with profound cardiogenic shock. Second, VV ECMO remains beneficial in severe ARDS, but clinicians must anticipate prolonged support and aggressively manage complications to improve outcomes. Third, emphasis should be placed on early referral and timely ECMO initiation, rather than delayed escalation or reliance on hybrid configurations.

In summary, this multicentric Indian study demonstrates that early VA ECMO initiation in aluminum phosphide poisoning results in favorable survival despite severe cardiogenic shock, while VV ECMO requires prolonged support and is associated with higher mortality, particularly in viral ARDS. These results highlight that timing, indication, and duration of ECMO support—rather than modality transition—are the key determinants of outcome in high-volume Indian critical care units [10–22].

This multicentric 9-year observational study demonstrates that extracorporeal membrane oxygenation (ECMO) outcomes in high-volume Indian critical care units are strongly influenced by indication-specific modality selection and timing of initiation. Veno-arterial (VA) ECMO showed better survival than veno-venous (VV) ECMO, primarily due to its early use in aluminum phosphide poisoning, a condition characterized by severe but reversible cardiogenic shock. When VA ECMO was initiated within 4–6 hours of poison ingestion, survival was favorable despite profound hemodynamic compromise, supporting ECMO as an effective bridge to toxin clearance and myocardial recovery. In contrast, VV ECMO required prolonged support in patients with severe ARDS and was associated with higher mortality, particularly during viral pneumonia and COVID-19–associated ARDS. Hybrid or transition ECMO played a negligible role in outcome determination in this cohort. Overall, the study highlights that early referral, timely ECMO initiation, and etiology-driven ECMO strategies—rather than late escalation or hybridization—are the key determinants of successful outcomes in Indian critical care practice. Limitations This study has several limitations. First, although multicentric, it was confined to high-volume centers in South Gujarat, which may limit generalizability to centers with lower ECMO volumes or different referral patterns. Second, the observational design precludes causal inference, and unmeasured confounders such as variability in pre-ECMO stabilization, referral delays, and center-specific protocols may have influenced outcomes. Third, the heterogeneous case mix—including toxicological emergencies, viral ARDS, and non-viral respiratory failure—limits disease-specific subgroup analysis. Fourth, long-term outcomes such as post-discharge survival, functional status, and quality of life were not assessed. Finally, due to the very small number of hybrid or transition ECMO cases, meaningful analysis of these configurations was not possible. Recommendations Based on the findings of this study, early initiation of VA ECMO should be strongly considered in aluminum phosphide poisoning, particularly when instituted within 4–6 hours of ingestion, even in patients presenting with severe cardiogenic shock. VV ECMO should continue to be utilized for severe ARDS, with anticipation of prolonged support and aggressive strategies to prevent infection, bleeding, and renal complications. Early referral to ECMO-capable centers and rapid decision-making are critical to optimize outcomes. Development of regional ECMO referral networks, standardized timing-based ECMO protocols for toxicological emergencies, and focused training programs may further improve survival in Indian settings. Future multicentric studies incorporating long-term outcomes and cost-effectiveness analyses are recommended to refine ECMO utilization strategies in resource-limited environments.

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