Heart–gut interaction in veno-arterial extracorporeal membrane oxygenation: a forgotten axis in critical care perfusion

The expanding use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock and post-cardiotomy support necessitates a focus on perfusion beyond traditional targets. The gastrointestinal tract (GIT) is particularly vulnerable, yet its dysfunction is often overlooked in ECMO management. This editorial synthesizes current literature and pathophysiological principles to analyze the mechanisms of GIT injury during VA-ECMO support. We examine the impact of VA-ECMO on hemodynamics, microcirculation, and inflammation, with a focus on the heart-gut axis. VA-ECMO compromises gut integrity through multiple interconnected pathways. These include microcirculatory dysfunction due to non-pulsatile flow and vasopressor use, increased left ventricular afterload, and ischemia-reperfusion injury. The phenomenon of “dual circulation” in peripheral VA-ECMO creates a risk of heterogeneous oxygen delivery, potentially leaving the GIT hypoperfused. These insults lead to mucosal barrier failure, bacterial translocation, and systemic inflammation, driving sequential organ failure. Early recognition of gut dysfunction, through clinical monitoring and biomarkers, is challenging but critical. Given the high morbidity and mortality associated with VA-ECMO, the GIT must be acknowledged as a critical target organ. A paradigm shift integrating gut-protective strategies, such as meticulous fluid management, enteral nutrition, and monitoring for signs of hypoperfusion into standard VA-ECMO protocols is essential to improve patient outcomes.