《Table 3 Aetiology,type of procedure and type of cannulation》

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《Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review》

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ATAAD:Acute type A aortic dissection；ECMO:Extra-corporeal membrane oxygenation；TEVAR:Thoracic endo-vascular aortic repair；AAA:Abdominal aortic aneurysm；EVAR:Endo-vascular aortic repair.

Our literature search revealed a limited number of relevant articles as expected.ECMO support following major aortic surgery has not been usually recommended because of its potential to further exacerbate lesions of the aortic wall and increased bleeding with delayed thrombosis of the false lumen due to the use of anticoagulation[60-62].Nevertheless，3 retrospective studies[32-34]and 1 observational study[31]（Table 2）have shown the feasibility of ECMO support in patients undergoing major aortic surgery for aneurysmal disease and dissection in contrast to current scepticism[29].In many countries the argument is to make for a balance between the costs involved in running ECMO support and select those patients who would benefit the most from a period of circulatory support following repair for acute aortic dissection.Monitoring the outcome of those patients who required ECMO support postoperatively and develop a specific database may be the way forward to shed further lights on the role of ECMO support in patients undergoing major aortic surgery.Although 1 retrospective study[34]has reported 88%mortality rate in 35patients who underwent ECMO support following surgical treatment for type A aortic dissection，there is no mention about indications for ECMO support；profile and co-morbidities of these patients；cannulation site（peripheral or central）；cause of death.Twenty-seven patients received ECMO support on the day of surgery and 8patients required ECMO support on postoperative day 1 or later.Most unusual，4additional patients with type A aortic dissection underwent ECMO support without surgical intervention but none of them survived.The other two retrospective studies[32，33]are more detailed with more favourable outcome in line with the extra corporeal life support organization registry[57，58].One study[33]included 36 patients who required VA-ECMO for post-cardiotomy failure following major aortic surgery.In-hospital mortality was 50%with multi-organ failure being the main cause of death.Preoperative levels of CK-MB>100 IU/L and peak lactate levels>20 mmol/L were considered relevant factors for in-hospital mortality.Retrograde flow cannulation was identified as another key factor for reduced survival compared to antegrade cannulation although the risk for early mortality is related to the preoperative clinical and haemodynamic status rather than the cannulation technique[62].The other study[32]compared short-and long-term outcomes between patients who required ECMO support and those who did not.In-hospital mortality was higher in the ECMO group（65%）compared to the non-ECMO group（8.5%）.Preoperative haemodynamic instability，aortic cross-clamp time and postoperative peak CK-MB were identified as predicting factors for postoperative ECMO support.ECMO survivors had younger age and less postoperative blood transfusion.Interestingly，those patients who survived after ECMO support following repair for acute type A aortic dissection showed a long-term survival rate comparable to patients who did not require ECMO support postoperatively.These findings were confirmed by a very detailed observational study[31]comparing patients with and without LV systolic dysfunction who underwent surgical intervention for acute type A aortic dissection.A total of 510patients were considered:86 with LV systolic dysfunction（group I）and 424 patients with preserved LV systolic function（group II）.ECMO support was required in 7patients from group I and in 10 patients from group II.The overall mortality was 79patients out of 510:20 from group I and 59 from group II.Multivariate analysis confirmed that a preoperative serum creatinine greater than 1.5 mg/dL and the requirement for ECMO support intra-operatively were significant independent predictors of in-hospital mortality but survival following ECMO support was not specified.Although patients with preoperative LV systolic dysfunction showed higher surgical risk for in-hospital mortality，their 3-year cumulative survival rate（77.8%）was comparable with those with preserved LV systolic function（82.1%）.Serial echocardiographic assessment did not show further deterioration of LV systolic function during the 3-year follow-up.