ECMO as a potential alternative to atrial septostomy This study and others highlight the usefulness of the Impella in children in whom VAD support is not a suitable option, and paves the way to continue the efforts to develop smaller devices for neonates and children.51 Intraaortic Balloon Pumping Counterpulsation The IABP (Maquet) augments diastolic coronary blood flow and reduces LV afterload, and has a well-established role as temporary partial support for adults with acute medical or postoperative cardiac failure There is limited experience of the IABP in children, but published reports describe its use in children with optimal single and biventricular surgical repair, and signs of acute circulatory failure with persistence of hypotension, metabolic acidosis, and low urine output.52 The insertion of IABP has been performed by percutaneous technique in children and adolescents, whereas in infants and neonates, an open surgical technique would be needed.53,54 Balloon sizes ranging from 2.5 to 7 mL are available for infants and children.55 Correct placement requires echocardiographic and/or fluoroscopic guidance Balloon inflation should occur in diastole and is synchronized with either the R wave from the electrocardiogram or with simultaneous images of the aortic valve and the balloon from echocardiography IABP weaning is based on gradual improvement of ventricular function and reduction of pharmacologic support, with stepwise reduction of balloon inflation from 1 : 1 to 1 : 3 over 48 hours.54 Results of IABP in children are limited to a small number of clinical series Weaning from IABP is reported to be between 44% and 75%, and of those weaned successfully, survival to discharge ranges between 25% and 65%.53,54 The limited widespread implementation of the IABP relates to technical limitations, the oftenchallenging nature of circulatory failure in congenital heart disease, its inability to support the right ventricle, and the fact that LV support provided is somewhat limited TandemHeart The TandemHeart (CardiacAssist) was initially designed as a left atrial-tofemoral bypass system that provides rapid circulatory support in patients with cardiogenic shock and pulmonary edema.56 More recently the TandemHeart has been used with a dual-lumen cannula inserted into the PA with and without an oxygenator to support patients with primary RV failure, and in patients with concurrent LVAD and failing RV.57 The system is percutaneously inserted via the femoral vein and advanced across the interatrial septum into the left atrium and returns it to one of both femoral arteries via the arterial cannulas Oxygenated blood is propelled throughout the system by a six-bladed continuous-flow centrifugal pump The pump is capable of delivering 5 liters per minute of cardiac output and can provide short-term support from a few hours up to 14 days.58 Pediatric experience with this device is limited, with only a few reports in the literature One of those reports details the placement of the TandemHeart in three children with ages ranging between 9 and 15 years.59 The authors deployed the device in two children as RV assist, after cardiac transplantation with severe RV dysfunction from elevated PVR due to restrictive cardiomyopathy In both children, the inflow cannula was percutaneously placed in the right femoral vein and inserted to the RA The outflow cannula was surgically inserted in the PA One of the patients survived cardiac transplantation with device explantation on postoperative day 4 The possibility of surgical placement of the cannulas after cardiopulmonary bypass makes the TandemHeart a potential option in children with congenital heart disease At the same time, the required large cannulas and the absence of meaningful conclusions of superiority over other devices will continue to preclude its use in children High-Risk Patient Groups Among patients with congenital heart disease, complex palliated circulations such as the Fontan circulation were associated with poor outcomes and were considered by many unsuitable for extracorporeal support.60,61 Currently, while they still represent a higher risk subgroup, most centers would now offer ECLS for patients with a failing circulation after Fontan operations or bidirectional cavopulmonary shunts, though the search for residual anatomic lesions should begin early in these patients.62,63 Young infants after stage 1 palliation for hypoplastic left heart syndrome and its variants were previously considered to be poor candidates for ECLS While they continue to present a challenge, they now represent a significant proportion of all cardiac ECLS, and their survival is more comparable to that of other patients with congenital heart disease This improvement may be in part related to earlier institution of support, increased use of VAD, and refined approaches to shunt management.64,65 Extracorporeal Cardiopulmonary Resuscitation ECPR is the initiation of venoarterial ECMO during active cardiopulmonary resuscitation ECPR in children was initially implemented in the early 1990s as a rescue therapy for myocardial dysfunction and cardiac arrest during cardiac surgery66,67 and in the pediatric ICU in patients with sepsis, myocarditis, and arrhythmias.68 The most recent report from the ELSO registry determined that more than 3000 ECPR runs occurred from 2009 to 2017, with overall survival to hospital discharge of 43% and a mean ECMO duration of five days.2 ECPR provides important advantages over CPR without ECMO, particularly in situations of prolonged resuscitation, where the mortality and morbidity are particularly high Published ECPR experiences have showed decreased mortality, improved systemic oxygen delivery during resuscitation, enhanced thermoregulation, and hemodynamic stability during the post arrest stage.40,69,70 The key to successful ECPR with acceptable long-term outcomes lies in the early and careful decision-making and team activation, and minimizing the time taken to cannulation and limiting the administration of cardiotoxic drugs during active conventional CPR.71 However, even in the most ideal settings, neurologic injuries remain common.72,73 Currently research efforts are focusing on the improvement of neurologic outcomes by maintenance of quality CPR and the early management after ECPR to help provide adequate support to these patients.2,74 Transporting Patients on Extracorporeal Life Support ECLS transport established the referral of patients in need of cardiorespiratory extracorporeal support from local or remote centers not performing in-house ECLS to centers that do The ECLS centers must have a mobile ECLS program, capable of performing V-V or V-A ECMO cannulations at the referring facility, or to transport an already cannulated patient In recent years, mobile ECLS programs have evolved to where geographic factors and weather-related issues are no longer an absolute contraindication to complete a transport, as the availability of specialized medical personnel, custom aircrafts, and safety during transport have increased.75,76 Most ECLS transport teams include an ICU physician, an ECLS specialist (nurse, respiratory therapist or perfusionist), and ... The pump is capable of delivering 5 liters per minute of cardiac output and can provide short-term support from a few hours up to 14 days.58 Pediatric experience with this device is limited, with only a few reports in the literature One of those reports details the placement of the TandemHeart... rescue therapy for myocardial dysfunction and cardiac arrest during cardiac surgery66,67 and in the pediatric ICU in patients with sepsis, myocarditis, and arrhythmias.68 The most recent report from the ELSO registry determined that