{'fraction_non_alphanumeric': 0.016937967443906733, 'fraction_numerical': 0.002419709634843819, 'mean_word_length': 5.878971255673222, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
The Horizon is Always Ahead.

In this issue of ASAIO Journal, two case reports describe native lung recovery following prolonged veno-venous extracorporeal membrane oxygenation (VV-ECMO).1,2 Until recently, dependence on extracorporeal life support (ECLS) beyond several weeks was felt to portend an ominous prognosis. Without signs of native lung recovery, catastrophic ECLSrelated complications seemed inevitable. However, there has been growing enthusiasm for VV-ECMO of extended duration, both supportive while awaiting lung recovery or as bridge to lung transplantation. These two case reports highlight some important issues that any program experienced in prolonged ECLS will confirm. Both centers minimized sedation and either managed the patient awake and extubated or on ventilator settings that would avoid barotrauma and encourage negative pressure breathing. Patients participated in physical rehabilitation, avoided persistent recumbency, and engaged in their own health care decisions. Our center has also experienced care of patients on VV-ECMO for extended duration and has encountered similar ethical and psychosocial challenges. Clearly, discussions with patients and families about goals and expectations must begin early in their ECMO course and reassessed as conditions evolve. There are several major innovations which have impacted ECLS care and safety, thus creating opportunities for patients to remain on support longer. The introduction of polymethylpentene hollow fibers into gas exchange devices produced durable, low-resistance ECLS oxygenators which reduce cellular activation and carry a small footprint, facilitating patient ambulation.3 Centrifugal blood pumps with Mendler design improves washing of blood contacting surfaces and reduces thrombus formation.4 Furthermore, magnetic levitation of rotors eliminates excessive heat generation, reducing hemolysis and thrombosis.5 Surface coatings within tubing and gas exchangers diminishes the inflammatory response of blood:surface interaction.6 New cannula design with dual lumen and bicaval insertion technique allows for femoralfree single site cannulation with enhanced patient mobility and improved gas exchange efficiency.7 There has also been advancement in our understanding of patient management on VV-ECMO, including importance of minimal sedation, negative pressure spontaneous breathing, participation in physical therapy, and ambulation. We also have learned that bleeding remains the most frequent ECLS-related complication, and that reduction or even elimination of systemic anticoagulation may be appropriate in certain clinical settings. Finally, the ECLS community has gained an appreciation of the previously under recognized potential for lung recovery in the setting of acute respiratory distress.8 While substantial progress has been made, there remains work to be done. The inflammatory and procoagulant blood:surface interactions must be mitigated with more effective and durable surface coatings. Sheer forces generated by current centrifugal blood pumps can create suction, microcavitation, and may exacerbate bleeding diathesis via destruction of von Willebrand Factor multimers.9 Novel pumps are needed that can satisfy the requirements for ECLS without these drawbacks.10 Cannula designs can be further improved with simpler insertion techniques and better flow characteristics. Servo-regulated ECLS systems that can automatically adjust flow and sweep based upon dynamic patient characteristics would improve safety, effectiveness, and potentially expand use to remote centers. Care networks need to be established where patients in respiratory or cardiac duress can have ECLS support initiated immediately before end organ injury, and transferred safely to regional high volume ECLS centers of excellence. Extracorporeal life support has come a long way from Hill and Bartlett. While we celebrate the seemingly miraculous triumphs reported here, we must also recognize that the ECLS advancements which allowed these successes only occurred from collaboration among innovators in the laboratory, industry, and at the bedside. Organizations like ASAIO are essential in providing the fertile ground for cultivation of ideas between those that share a similar passion but possess diverse backgrounds and skills. We must continue to share our successes along with our failures to disseminate awareness of the present day, encouraging our colleagues, competitors, students, and mentors to initiate the next great innovation for tomorrow.