VA-ECMO requires careful weaning as cardiac and pulmonary recovery is closely evaluated. This usually involves waiting for patient recovery from severe end-organ damage (pulmonary edema, hepatic dysfunction), near resolution of vasopressor requirements and near euvolemic status. Cardiac function is evaluated with serial echocardiograms. When deemed appropriate by the multidisciplinary intensive care unit team, ECMO flow is reduced under close hemodynamic and echocardiographic monitoring. The ECMO flow rate is reduced slowly with concurrent up-titration of ionotropic support. The usual goal is to observe adequate native CO in the setting of less than ~1 to 2 L/min of ECMO flow. A small heparin bolus is usually given before flow reduction (turndown) to reduce the risk of thrombus formation at reduced ECMO flows. Lower flows are only tolerated for a short time to avoid clot formation. If the turndown is tolerated, then the patient is taken to the operating room for removal.