Maximizing cardiopulmonary support as a minimally invasive platform—using peripheral parallel veno-venous and veno-arterial extracorporeal membrane oxygenation and axillary impella 5.5 as a bridge to heart–lung transplantation

Combined heart–lung transplantation (HLTx) in patients with cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) presents a major physiologic challenge. Conventional ECMO strategies may inadequately address simultaneous refractory hypoxemia, circulatory failure, and left ventricular (LV) distension without central cannulation and sternotomy. A 65-year-old man with severe heart failure (LVEF <10%) and rapidly progressive interstitial lung disease presented with cardiogenic shock and hypercapnic hypoxemic respiratory failure. Initial V-AV ECMO provided stabilization and allowed extubation and expedited HLTx evaluation. Progressive hypoxemia and acute kidney injury despite maximal V-AV support prompted escalation to peripheral parallel VV–VA ECMO. Echocardiography demonstrated LV distension, prompting axillary Impella 5.5 placement for decompression. The patient remained awake and extubated on parallel VV–VA ECMO and Impella 5.5 for 60 hours prior to successful heart–lung transplantation. We report the novel application of a fully peripheral cardiopulmonary support platform as a viable bridge strategy for HLTx candidates.