Beyond Conventional VV-ECMO: The Role of Veno-Pulmonary Support in Trauma-Associated ARDS With Right Ventricular Dysfunction

Severe acute respiratory distress syndrome (ARDS) after trauma can require extracorporeal support, however, the usual approach to ARDS is often complicated by associated injuries. Prone positioning may be limited by unstable fractures or other injuries, while traumatic intracranial hemorrhage and recent bleeding can make systemic anticoagulation difficult. At the same time, severe ARDS can substantially increase right ventricular afterload and lead to right ventricular dysfunction. Conventional venovenous extracorporeal membrane oxygenation (VV-ECMO) improves gas exchange and may reduce right ventricular afterload indirectly, but it still relies on native right ventricular forward flow. Veno-pulmonary (V-P) ECMO offers an alternative by combining extracorporeal gas exchange with direct right ventricular unloading. Most published experience, however, has involved conversion to V-P support after refractory right ventricular failure has already developed. This review examines the role of V-P ECMO in severe trauma-associated ARDS, focusing on right ventricular dysfunction, selection of the initial extracorporeal configuration, and anticoagulation when traumatic bleeding limits standard management. We also describe an illustrative multiply injured patient with severe ARDS, evolving right ventricular dysfunction, and traumatic subdural hemorrhage who received V-P ECMO as the initial configuration without systemic anticoagulation. Current evidence supports the feasibility of V-P ECMO but does not define when earlier direct right ventricular support is warranted. Trauma adds important constraints that make configuration and anticoagulation decisions particularly complex and deserving of further study.