For many clinicians, ECMO begins and ends with two familiar configurations: veno-venous (VV) for respiratory failure and veno-arterial (VA) for cardiopulmonary collapse. In practice, however, not every patient fits cleanly into those categories. 

As ECMO programs have matured, cannulation strategies have evolved to address more specific hemodynamic problems—particularly isolated right or left ventricular failure, inadequate ventricular unloading, or mixed cardiopulmonary shock. Rather than replacing VV or VA ECMO, these targeted approaches refine support to better match the underlying physiology and are used selectively in experienced centers. 

A Quick Review

Most clinicians are familiar with two primary ECMO configurations, which remain the foundational strategies for managing severe respiratory and cardiocirculatory failure: 

• Veno-venous (VV) ECMO: Provides respiratory support by draining venous blood, oxygenating it, and returning it to the venous circulation, relying on native cardiac function to maintain systemic perfusion. Indicated for severe respiratory failure, such as Acute Respiratory Distress Syndrome (ARDS) or refractory hypoxemia. 

• Veno-arterial (VA) ECMO: Provides both cardiac and respiratory support by draining venous blood and returning it to the arterial system, thereby bypassing the heart and lungs to maintain systemic perfusion. Indicated for conditions such as cardiogenic shock, cardiac arrest, and heart failure. 

Beyond Traditional VV and VA

In select cases, more targeted cannulation strategies are used to address isolated right or left ventricular dysfunction, optimize unloading, or combine circulatory support with tailored flow pathways. 

Right Ventricular Assist Device (RVAD)

An RVAD provides isolated mechanical support to the failing right ventricle, augmenting pulmonary blood flow while relying on native lung function for gas exchange. 

Purpose 

• Provides right ventricular unloading and circulatory support 

• Maintains forward flow through the pulmonary circulation 

• Does not provide extracorporeal oxygenation 

Blood Flow Pathway: Deoxygenated blood is drained from the right atrium or vena cava, passed through a mechanical pump, and returned directly into the main pulmonary artery, thereby bypassing the right ventricle while preserving native pulmonary gas exchange. 

Common Indications 

• Isolated acute right ventricular failure with preserved pulmonary gas exchange 

• RV failure following cardiotomy, myocardial infarction, or durable LVAD implantation 

• RV dysfunction due to pulmonary hypertension or pulmonary embolism with preserved oxygenation 

Cannulation 

• Drainage cannula positioned in the right atrium or vena cava 

• Return single-stage cannula positioned in the main pulmonary artery 

• Peripheral dual-lumen cannula inserted via the right internal jugular vein, draining from the right atrium and returning to the main pulmonary artery 

Veno-Pulmonary Arterial ECMO (V-PA ECMO)

V-PA ECMO utilizes the same RA→PA cannulation pathway as an RVAD but incorporates a membrane oxygenator into the circuit, providing both right ventricular support and extracorporeal gas exchange. 

Purpose:  

• Provides right ventricular bypass and unloading in acute RV failure. 

• Maintains forward flow through the pulmonary circulation via direct pulmonary artery return. 

• Delivers extracorporeal oxygenation and CO₂ removal 

Blood flow pathway: Drains deoxygenated blood from the venous system (right atrium or vena cava) and returns oxygenated blood directly into the pulmonary artery, thereby bypassing the right ventricle while supporting gas exchange independent of native lung function. 

Common indications: 

• Right ventricular failure with concomitant hypoxemia or hypercapnia 

• Pulmonary hypertension or pulmonary embolism causing RV failure and impaired gas exchange 

• Mixed cardiopulmonary shock requiring both RV support and extracorporeal oxygenation 

Cannulation: 

• Same RA–PA cannulation strategy as RVAD, with a membrane oxygenator 

Atrial–Venoarterial ECMO (LAVA-ECMO)

LAVA ECMO is a VA-based configuration used when conventional VA ECMO fails to adequately unload the left ventricle or is hemodynamically problematic due to increased afterload or significant aortic insufficiency. 

Purpose 

• Provides systemic circulatory support 

• Actively unloads the left atrium and ventricle 

• Reduces pulmonary edema and LV distention seen in conventional peripheral VA ECMO 

Blood Flow Pathway: Blood is drained from the left atrium via transseptal cannulation, passed through the extracorporeal pump and oxygenator, and returned to the systemic arterial circulation (typically the femoral artery) 

Common Indications 

• Severe LV failure with pulmonary edema 

• LV distention during peripheral VA ECMO 

• Cardiogenic shock where LV decompression is required, such as aortic insufficiency 

Cannulation 

• Transseptal puncture with cannula positioned in the left atrium 

• Arterial return cannula (usually femoral artery) 

Physiology First, Configuration Second

While these ECMO strategies differ significantly, they share one important principle: they are designed to solve specific physiologic problems, not to replace standard VV or VA-ECMO. 

For bedside clinicians, the most important takeaway is not memorizing configurations, but understanding: 

• What problem is this circuit trying to solve? 

• What does “success” look like for this patient? 

• How do hemodynamics, monitoring priorities, and potential complications differ from conventional ECMO? 

As ECMO programs continue to mature, these hybrid strategies are likely to remain selective tools, used thoughtfully by experienced teams rather than as routine options. 

At Integration Health, we see these emerging modalities as part of a broader shift toward individualized extracorporeal support, grounded in physiology, teamwork, and program readiness.