Background: Given the resource-intensive nature of ECMO, interest in payment of claims in the United States remains high. This study evaluated payment of ECMO claims by commercial payers. Methods: The first ECMO hospitalization per patient in the Inovalon commercial claims data set (January 2023–December 2024) was analyzed, using ICD-10 procedure codes to identify applicable hospitalizations. Commercial payers included commercial, commercial and Medicaid, marketplace, and self-insurance providers. Insurance payments and length of stay (LOS) were summarized (mean, median, standard deviation [SD], minimum, maximum) and stratified by ECMO type (venovenous, venoarterial, central). Hospital costs were unavailable in this dataset. Results: Central ECMO: Median payment was $427,853. The SD was $547,517. Minimum LOS was 1 day. Median and maximum LOS were 18 and 302 days, respectively. Venoarterial ECMO: Median payment was $293,052, and SD was $518,848. Minimum, median, and maximum LOS were 1, 20, and 310 days, respectively Venovenous ECMO: Median payment was $282,259, and the SD was $602,553. Minimum LOS was 1 day, the median was 26 days, and the maximum was 302 days. Conclusion: This analysis demonstrated the wide variation in payments for ECMO claims in the United States. Central ECMO had the highest median payment and the shortest median LOS, likely because of the greater severity of illness and earlier mortality among patients who receive ECMO via central cannulation. This analysis highlights the need for further research on the role of patient demographic characteristics, comorbidities, and treatment variation on the duration of ECMO and claims payment.

Ventricular septal defect (VSD) is a rare but potentially fatal complication of blunt-force trauma, leading to complex hemodynamic instability. While veno-arterial extracorporeal membrane oxygenation (VA ECMO) is documented in ischemic VSD, its use in traumatic cases is exceedingly rare. We present a novel use of central VA ECMO to stabilize cardiogenic shock and pulmonary recirculation secondary to traumatic VSD, serving as a bridge to orthotopic heart transplant (OHT) listing. A 33M without significant history sustained multisystem trauma during a high-speed motor vehicle collision and presented with profound shock. Initially presumed to be hemorrhagic, imaging later demonstrated a ruptured papillary muscle causing torrential tricuspid regurgitation along with a large VSD causing left-to-right shunting. An Impella CP and peripheral VA ECMO were placed and he was transferred to our center for surgical consideration. On mechanical circulatory support (MCS) Day #3 he underwent VSD patch repair and tricuspid valve replacement. However, patch dehiscence on postoperative Day #3 led to recurrent shunting and worsening pulmonary edema. Given limited options, high-flowing central VA ECMO (right atrium/pulmonary artery to aorta [RAPA-AO]) with proximal pulmonary artery banding was initiated and resulted in stabilization of VSD shunting, marked improvement in pulmonary edema, and return to participation with physical therapy. On MCS Day #19, the patient was accepted for OHT listing. This case illustrates the novel deployment of a central VA ECMO configuration to overcome unique physiological challenges of pulmonary recirculation in traumatic VSD. To our knowledge, there is limited reported use of VA ECMO in traumatic VSD.

Acute limb ischemia (ALI) is a major complication of acute mechanical circulatory support, including venoarterial extracorporeal membrane oxygenation (VA-ECMO). Passive bypass (PB) with a distal perfusion catheter (DPC) may mitigate ALI by supplying blood to the superficial femoral artery (SFA) from the contralateral limb. Active bypass (AB) provides pressurized blood flow to the limb by coupling a DPC to the VA-ECMO circuit. We explored if the distal limb perfusion index (DLPI), defined as the ratio of mean arterial pressures (MAP) in the SFA and radial artery, identifies limb hypoperfusion and may be used to monitor the hemodynamic efficacy of limb salvage strategies in patients requiring peripheral VA-ECMO for cardiogenic shock. SFA-MAP was measured using a pressure wire. Limb tissue oxygenation was measured using near infrared spectroscopy (NIRS). Data were collected before and after arterial cannula insertion, with PB before VA-ECMO activation, and with AB after VA-ECMO support. Six subjects were enrolled. Arterial cannula insertion significantly reduced SFA-MAP (p<0.01) and the DLPI (p=0.02; Figure). PB before VA-ECMO activation failed to raise SFA-MAP (p=0.72) or DLPI (p=0.46). In contrast, AB significantly increased SFA-MAP(p=0.02) and DLPI (p<0.01) after cannula insertion and, compared to PB, provided superior increases in SFA-MAP (p=0.03) and (p=0.001). NIRS values were non-significantly changed across all conditions. The DLPI is a novel index that identifies limb hypoperfusion and demonstrates that pressurized perfusion with AB may be superior to PB through a DPC.