Integrated Use of Extracorporeal Membrane Oxygenation and Molecular Adsorbent Recirculating System for Refractory Cardiotoxic Ingestion: A Single-Center Case Series.
Ehrhardt T, Zalesky C, et al. • Critical care explorations • 2026
A coordinated regional protocol enabling early access to ECMO and MARS is feasible in massive cardiotoxic ingestions, with four of five patients surviving to discharge.
Key Findings
Results
All five patients with severe cardiotoxic ingestions received MARS therapy for drug clearance and vasoplegia management, with four surviving to hospital discharge.
Five consecutive patients with severe cardiotoxic ingestions (calcium-channel blockers and/or beta-adrenergic antagonists) were managed via a regionally triggered transfer pathway
Four of five patients (80%) survived to discharge; one patient died due to profound myocardial poisoning
All patients presented with profound hypotension and respiratory failure despite standard therapies prior to transfer
This represents a single-center case series, limiting generalizability
Results
Two of five patients required venovenous ECMO for refractory hypoxemia in addition to MARS therapy.
Venovenous (VV) ECMO was used specifically for refractory hypoxemia, not solely for cardiogenic shock
The use of VV-ECMO in cardiotoxic ingestions is described as 'underexplored' in the literature
Venoarterial ECMO is the more commonly recognized rescue therapy for cardiogenic shock from cardiotoxic ingestions
The combination of VV-ECMO and MARS represents an integrated multi-modality extracorporeal support approach
Results
MARS (molecular adsorbent recirculating system, a form of albumin dialysis) was used in all five cases for drug clearance and management of vasoplegia.
MARS was applied to all five patients, making it the universal extracorporeal intervention in this series
The dual therapeutic targets of MARS were drug clearance and vasoplegia management
The role of albumin dialysis specifically in cardiotoxic ingestions is described as 'underexplored' prior to this report
Calcium-channel blockers and beta-adrenergic antagonists are highly protein-bound drugs, which is the mechanistic rationale for albumin dialysis
Results
A coordinated regional transfer pathway was used to link patients to extracorporeal therapies, and this approach was found to be feasible.
The protocol is described as a 'regionally triggered transfer pathway'
All five patients were transferred to the single center capable of providing ECMO and MARS
Early access to ECMO and MARS through a coordinated regional protocol is characterized as feasible for massive cardiotoxic ingestions
The effectiveness of linking patients to therapy through a coordinated referral process was identified as an underexplored area prior to this report
Results
Complications from the integrated extracorporeal support approach included continuous renal replacement therapy (CRRT) filter clotting and catheter-associated thrombosis.
CRRT filter clotting was identified as a complication, suggesting concurrent renal replacement therapy was used alongside MARS and ECMO
Catheter-associated thrombosis was also documented as a complication
These complications reflect the complexity and risks of managing multiple simultaneous extracorporeal circuits
The complication profile is reported descriptively in a case series of five patients
Background
Cardiotoxic ingestions of calcium-channel blockers and beta-adrenergic antagonists are described as highly lethal, often causing refractory vasoplegic shock and noncardiogenic pulmonary edema.
The toxidrome includes both refractory vasoplegic shock and noncardiogenic pulmonary edema as major features
Standard therapies were insufficient in all five cases, necessitating advanced extracorporeal rescue
Vasoplegia (distributive shock) rather than cardiogenic shock alone was a prominent feature requiring targeted management
This pathophysiology informed the selection of both MARS (for vasoplegia and drug clearance) and ECMO (for respiratory and/or circulatory failure)
What This Means
This research describes five patients who were critically ill after ingesting toxic amounts of heart medications — specifically calcium-channel blockers or beta-blockers — drugs that can cause catastrophic drops in blood pressure and severe breathing failure. All five patients were transferred to a single hospital through a coordinated regional protocol specifically designed to quickly connect these patients with advanced life support machines. Every patient received a specialized liver dialysis treatment called MARS (molecular adsorbent recirculating system), which filters the blood using albumin to help remove the toxic drugs and stabilize blood pressure. Two of the five patients also needed a heart-lung bypass machine (venovenous ECMO) to support their breathing. Four out of five patients survived and were discharged from the hospital, while one patient died because the heart damage from the poisoning was too severe to overcome.
This research suggests that combining MARS albumin dialysis with ECMO — and organizing a regional system to rapidly transfer patients to centers that offer these therapies — may improve survival in what is otherwise a highly lethal type of poisoning. Both VV-ECMO for breathing failure and MARS for drug removal and blood pressure support are not widely reported in this context, making this case series one of the first to describe their integrated use. Complications did occur, including blood clots in the dialysis filters and around catheters, highlighting that this approach is complex and carries risks.
The broader implication of this research is that having organized regional transfer networks and access to specialized extracorporeal support technologies may be critical for patients with severe medication overdoses who do not respond to standard treatments. The findings suggest that early transfer to a capable center — before patients deteriorate further — could be a key factor in improving outcomes, though larger studies would be needed to confirm these observations given the small number of patients reported here.
Ehrhardt T, Zalesky C, Shepherd A, Chan J, Subramanian R, Jabaley C, et al.. (2026). Integrated Use of Extracorporeal Membrane Oxygenation and Molecular Adsorbent Recirculating System for Refractory Cardiotoxic Ingestion: A Single-Center Case Series.. Critical care explorations. https://doi.org/10.1097/CCE.0000000000001499