Abstract
Background
Extracorporeal Life Support (ECLS) services are characterised by variability in resource availability, specific expertise, device management and team organisation, especially regarding the role of perfusionists. This international survey aimed to investigate perfusionists’ education, training and role within the ECLS team.
Methods
This is a descriptive, self-reporting, cross-sectional, voluntary, confidential international survey addressed to professionals involved in ECLS management, including perfusionists. The survey was distributed from April to August 2025 through congress, newsletter and social media platforms.
Results
A total of 178 ECLS centres submitted completed surveys. Most centres provided both cardiac and respiratory support (n = 153, 86%) for over 10 years (n = 117, 65.2%). Perfusionists, mainly holding a bachelor’s degree (n = 77, 47.5%), were reported to be responsible for ECLS device in 87.1% (n = 155) of centres, including priming (n = 156, 87.6%), setting management (n = 123, 69.1%), circuit/membrane lung replacement (n = 151, 84%) and running the emergency hand-crank (n = 133, 74.7%); though roles were often shared with multidisciplinary teams. Perfusionists were reported as part of retrievals/transports teams by 81.5% (n = 145) of responders. Education practices were reported as heterogeneous, with limited periodic ECLS-specific training programs (monthly: n = 19, 10.7%; every 6 months: n = 48, 27%; yearly: n = 31, 17.4%; no continuous education provided: n = 55, 30.9%).
Conclusions
This international survey revealed marked variability in perfusionist education, training and roles within the ECLS teams, and related organization. Despite their technical responsibilities, a growing multidisciplinary collaboration is reshaping team dynamics. The absence of a standardized education remains a critical gap, requiring appropriate actions and planning by professional and scientific societies.
Keywords
Introduction
The use of extracorporeal life support (ECLS) has expanded considerably 1 with evolving and new clinical indications, reaching unprecedented peaks during the COVID-19 pandemic.2–7 However, the organization of ECLS programs remains highly heterogeneous,8,9 with differences in protocols, staffing models, personnel experience, resources availability, and the specific role of healthcare professionals.9–12
Perfusionists play an important role in ECLS setup, daily management and troubleshooting.9,11 Nevertheless, their training, involvement and responsibilities vary widely across centres, often being shared with specialised nurses or physicians, acting as Extracorporeal Membrane Oxygenation (ECMO) specialists. 13 Despite the publication of international guidelines14,15 and position papers,11,16 significant gaps persist in the practical implementation of ECLS-related standards, 8 particularly regarding the role of perfusionists within the ECLS team. Such a situation was investigated in 2014 by Vercaemst et al. 9 Since then, major changes in ECLS indications, case volume, multidisciplinary organization, and the impact of the COVID-19 pandemic have occurred, leaving a lack of contemporary international data on how perfusionists’ roles and training have evolved over the past decade. Moreover, specific areas for improvement and actual needs require further exploration. Based on the above-mentioned premises, this international survey aimed to investigate the clinical and organisational practices regarding the role of perfusionists within the ECLS team. The survey design included five key issues: characteristics of ECLS hospitals; perfusionists’ general training and specific ECLS training; role of perfusionists and other clinicians within the ECLS team; daily management of ECLS tasks; and management of emergencies. We hypothesised that a significant heterogeneity still exists regarding the five above-mentioned domains, and the current survey will support the development of targeted actions to further define the perfusionist’s profile within the ECLS community.
Methods
Survey design and development
A descriptive, self-reporting, cross-sectional, semi-structured voluntary international survey was developed based on 28 questions covering five items: characteristics of ECLS hospitals; perfusionists’ general training and specific ECLS training; role of perfusionists within the ECLS team; daily management of ECLS tasks; management of emergency situations. The survey included multiple choice and open-end (free text) questions.
The survey was developed by a team of perfusionists (DT, CS, MCC) and cardiothoracic surgeons (SM). The structure of the survey was revised by external reviewers (RL, JS, LV, GD, JS, MB). The survey was validated by perfusionists from the promoting institution and one external institution, who were not involved in its finalization. Feedback about readability, clarity, ease of completion and time required to complete the survey were recorded during the validation phase. This research was conducted in accordance with applicable national and European regulations on research and data protection, including GDPR. As the survey did not involve patients or sensitive data, ethics committee approval was not required. Centre identifiers (hospital name and country) were temporarily collected to enable deduplication at centre level. Where multiple responses originated from the same centre, the most complete was kept. The identifiers were removed prior to analysis and the data were analysed in de-identified form. This survey was conducted and reported according to the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) 17 and endorsed by the European Chapter of the Extracorporeal Life Support Organization (ELSO).
Distribution of the survey and target population
The survey was conducted through an internet-based tool (Qualtrics, Provo, UT), distributed among the ELSO members through newsletters, promoted during the 2025 annual EuroELSO congress, and advertised through social media. Participation was open to both ELSO and non-ELSO centres worldwide. The survey was disseminated from April 2025 to August 2025. An English-only version of the survey was provided and participation was voluntary.
The primary target population included all clinical perfusionists. Invitation was extended to other clinicians in order for them to complete the survey on behalf of their perfusionists, when appropriate. The absence of a clinical perfusionist within the ECLS team was an exclusion criterion for enrolment. Questions about the number of runs for respiratory and circulatory support undertaken in each centre was referred to the year 2019 while all other questions were referred to the situation present in each centre at the moment of survey dissemination (2025).
Data analysis
Data were exported into Microsoft Excel (Washington, USA, Version 16.35) and reviewed. Unsubmitted and empty surveys and surveys with data completeness <40% were excluded. The number of respondents to each question was recorded, and each question was analysed separately. The answers were combined in case of more than one response from a single centre. In case of conflicting responses, the most completed survey was retained. The amount and structure of missing data (Supplemental Table 1) did not allow a reliable formal test of the missing at random (MAR) mechanism. Little’s missing completely at random (MCAR) test was not identifiable and logistic models on missing indicators showed complete/quasi-complete separation. Therefore, missingness was assumed to be at least MAR.
Variables were expressed as numbers (percent on available data, excluding missing values) for categorical variables and median (with interquartile range) for continuous variables. All descriptive statistics were performed on original data, and no imputations were performed. Categorical data were compared between groups with Pearson’s Chi-Square, Fisher’s exact test or the Fisher-Freeman-Halton Exact Test, as appropriate. Continuous variables were analysed using the independent-samples t-test or Mann-Whitney U test, as appropriate. The descriptive analyses addressed differences between low-volume (≤30 ECLS cases/year) and high-volume (>30 ECLS cases/year) centres16,18 stratified based on their yearly volume of circulatory support runs and respiratory support runs in 2019 (Supplemental Tables 3–8). The cut-off value of 30 cases/year was chosen based on the recommended minimum ECLS case volume suggested by Abrams et al. 16 Characterisation of the yearly volume based on ECLS runs in 2019 was chosen to avoid pandemic distortions, while all other survey questions were referred to the circumstances at the time of survey completion. A sensitivity analysis was performed after exclusion of centres that submitted multiple surveys and required conflict resolution (n = 38). A 2-sided p-value <0.05 was considered as statistically significant. All data were merged from de-identified files into SPSS 26.0 (IBM, New York, USA), and R 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria) for statistical analysis.
Results
Characteristics of the participating centres
From April 10th to August 14th 2025, a total of 830 accesses to the online survey form were recorded. After removal of unsubmitted (n = 308/830, 37.1%), incomplete (defined as survey progress <40%; n = 267/830, 32.2%; absence of perfusionists in the team n = 24/830, 2.9%), and duplicate (n = 55/830 from 43 centres, 6.6%) surveys, a total of 178 (21.5%) surveys from an analogous number of centres (Figure 1, Supplemental Figure 1 and Supplemental Table 2) were included in the analysis. Contributing centres. Number and distribution of centres that submitted a survey included in the final analysis.
Centres characteristics.
Data are reported as n (% as valid percentage excluding missing values).
Abbreviations: ELSO: extracorporeal life support organization; ECLS: extracorporeal life support.
Perfusionists’ general and specific ECLS training
The minimum educational level required to become a clinical perfusionist was most commonly a bachelor of science degree (n = 77, 43.3%), followed by a graduate certificate (n = 45, 25.3%, Figure 2(a)). In 78.7% (n = 140) of centres, new perfusionists undergo supervised training before independent work, and 36% (n = 64) attend structured courses or simulation programs (Figure 2(b)). However, 9.6% (n = 17) of participants declared that no formal introductory training is currently required in their institution. The duration of the introductory training varied widely (Table 2), with 1-month (n = 21, 11.8%) and 6-month (n = 46, 25.8%) programs being the most frequent durations. Most participants reported that continuous education courses/training on ECLS are never performed (n = 55, 30.9%) in their institutions, or performed every 6 months (n = 48, 27%; Figure 2(c)), with a higher frequency in centres with less years of ECLS activity (Supplemental Table 9). Perfusionist’s education and training. (a) Minimum level of basic training to become a clinical perfusionist. (b) Local required introduction training before working as independent clinical perfusionist. (c) Frequency of continuous education required to be part of the local Extracorporeal Life Support (ECLS) team. Perfusionist’s training. Data are reported as n (% as valid percentage excluding missing values) or median (1st-3rd quartile). Abbreviations: ECLS: extracorporeal life support.
Role of perfusionists and other clinicians within the ECLS team in daily and emergency tasks
Extracorporeal life support management.
Data are reported as n (% as valid percentage excluding missing values).
Abbreviations: ELSO: extracorporeal life support organization; ECLS: extracorporeal life support; ECMO: extracorporeal membrane oxygenation; ML: membrane lung; CRRT: continuous renal replacement therapy; OR: operating room; cath lab: catheterization laboratory; CT: computed tomography.
Roles in daily and emergency Extracorporeal Life Support (ECLS) management.
The sensitivity analysis after exclusion of centres that submitted multiple surveys and required conflict resolution demonstrated similar results compared to the main analysis (Supplemental Table 10–12).
Secondary analyses based on centre ECLS yearly volume
Two secondary analyses were conducted based on circulatory (Supplemental Table 3–5) or respiratory (Supplemental Table 6–8) ECLS volume. Heart transplant and implantable ventricular assist devices were reported to be available in 38.6% (n = 39) and 46.5% (n = 47) of low-volume centres for circulatory ECLS, and 66.2% (n = 43; p < 0.001) and 81.5% (n = 53; p < 0.001) in high-volume centres (Supplemental Table 3). A similar result was observed for lung transplants concerning respiratory ECLS (low-volume: n = 28, 25.9%; high-volume: n = 20, 40.8%; p = 0.061). Most high-volume centres for circulatory ECLS reported treating neonatal, paediatric and adult patients (n = 30, 46.2%) while most low-volume centres reported treating adults only (n = 53, 52.5%; p = 0.005). Similar responses were provided for the respiratory ECLS groups (p = 0.006).
No significant differences were reported between low- and high-volume centres regarding introduction training practices, frequency of continuous education and perfusionists’ responsibilities. The use of a cannulation checklist was reported to be more common in high-volume centres for circulatory support (low-volume: n = 51, 50.5%; high-volume: n = 43, 66.2%; p = 0.047) and the use of a checklist for transport inside the hospital was reported to be more common in low-volume centres for respiratory support (low-volume: n = 65, 60.2%; high-volume: n = 19, 38.8%; p = 0.013).
Discussion
This international survey provides an updated overview of the role, education and responsibilities of perfusionists within ECLS programs worldwide. The study highlights how perfusionist involvement in ECLS management has evolved, revealing current heterogeneity in team composition, training structures, and clinical responsibilities. This study has four main findings. First, most participating ECLS centres have long-established ECLS programs, but 60–70% of them perform less than 30 circulatory and/or respiratory runs. Second, there is still a marked international variability in perfusionists’ training and continuous education. Third, the perfusionists’ role remains central, especially concerning the ECLS device management, circuit assembling and priming, and troubleshooting. Fourth, ECLS management is shared within a multidisciplinary team with a significant degree of variability, underscoring the need to understand which model is the most effective, efficient and sustainable to follow.
Most responses were obtained from ECLS centres located in Europe and United States, reflecting the geographic distribution of ECLS institutions and the networking interactions that allowed the survey distribution. Although the global spread and long experience of many centres suggest that ECLS is now an integral part of intensive care services, the low annual volume of many centres might raise concerns about the organisation of ECLS networks and the lack of structured centralisation in high-volume centres. Literature supports the development of a regionalized model that focuses on delivering specialised care capable of treating more patients, more effectively and efficiently. 19 Centralising patients might also favour their access to advanced end-stage heart and lung failure therapies. The frequent coexistence of heart/lung transplantation and ventricular assist device programs in high-volume centres further suggests that the highest number of ECLS cases are performed in centres with advanced cardiothoracic expertise and infrastructure, which may influence staffing and perfusionists’ involvement.20,21
Our findings confirm a wide international variability in perfusionist education.9,22 While most respondents reported holding at least a bachelor’s degree, the structure and duration of training programs differ substantially, with a median duration of 2 years. This reflects the absence of a unified international framework, as also reported by Vercaemst et al. (2014).9,10 Although 78.7% of centres require supervised training under a senior perfusionist, structured simulation courses23,24 or certification programs were reported in only one-third of cases, and nearly 10% indicated that no formal introduction is required. This variability raises concerns about the standardisation of competencies, particularly as ECLS management expands beyond traditional cardiac surgery settings. While the survey explored introductory training, it did not explicitly distinguish between independent on-call activity immediately after training and supervised integration that could be addressed in future studies. Future efforts should be made to apply the recently published consensus statement on basic qualifications and competencies for clinical perfusionists in Europe, to recognise a unified programme for minimum standards of education, training of new recruits and continuous education. 11
Continuous professional development appears equally heterogeneous, with no regular ECLS-specific training and/or re-training. This finding suggests that many institutions rely heavily on experiential learning rather than systematic skill reinforcement. Given the progressive expansion of ECLS-related responsibilities across professional roles and the challenging nature of circuit management, the establishment of standardized, periodic training and credentialing programs remains a key consideration for ECLS programs.11,25 Indeed, a recent expert consensus statement from the European Board of Cardiovascular Perfusion in collaboration with European Association for Cardio-Thoracic Surgery and European Association for Cardio-Thoracic Anaesthesiologists and Intensive Care outlines core qualifications, competencies and recommended training pathways for perfusionists across Europe for safe and independent practice. 11 Moreover, credentialing programs such as the one proposed by the European Board of Cardiovascular Perfusion are encouraged, with possible integrations and titration on ECLS responsibilities.
Perfusionists remain the primary professionals responsible for setup, priming, circuit surveillance, and troubleshooting in most centres. 12 However, daily and emergency responsibilities are increasingly shared with nurses, physicians, and dedicated ECMO specialists, with geographical variations. These task-sharing models can enhance sustainability when accompanied by rigorous training and oversight, 9 without replacing the primary technical responsibility of perfusionists. This evolution likely results from the increasing use of ECLS in non-cardiac surgery centres, the need for 24/7 coverage (70.4% of centres declared to have perfusionists on call, and 24.7% to have a 24/7 in-hospital perfusionist) and the integration of ECLS into intensive care workflows. Such models have been shown to improve flexibility and workload distribution,26,27 but they also require clearly defined competencies and communication pathways. In this context, availability appears to affect the extent to which perfusionists are involved in ECLS teams, particularly in larger centres with advanced programs. Future consensus efforts should aim to define minimal standards for perfusionist involvement according to centre type, case volume, range of ECLS-related activities performed and staffing resources.
Compared with an earlier conducted survey, 9 the present study reveals both continuity and evolution. While perfusionists remain central to ECLS management, their role is increasingly influenced by interdisciplinary dynamics and institutional organisation.20,28 The persistent lack of standardization in training and credentialing echoes prior findings and highlights ongoing barriers to global harmonization. 9 These results support the growing recognition that successful ECLS programs rely not only on technical proficiency but also on structured teamwork, continuous education, and quality assurance processes. International organizations play a key role in developing harmonized curricula, certification standards, and multidisciplinary training initiatives, fostering safer and more efficient ECLS delivery (e.g. ELSO Excellence Centre Program, which recognizes institutions that meet defined criteria for education, quality, and multidisciplinary ECLS practice).
In this analysis, centres were divided according to the volume of ECLS runs per year. 16 The results suggest that high-volume ECLS centres are characterised by greater availability of advanced resources and expertise on neonatal, paediatric and adult patients. Despite these differences, most organisational aspects regarding the role of perfusionists are consistent across centres. Minor differences were noticed regarding the structure of initial trainings, frequency of continuous education, or the use of checklists. Nevertheless, the volume characterisation of each centre was based on pre-pandemic data that might have introduced a recall bias and a mismatch between current practices and pre-pandemic ECLS volumes. For these reasons, larger systematic investigations are required to test volume-based possible differences in a higher number of centres.
Limitations of this study may include potential selection and information biases. Centres with well-established ECLS programs and with active involvement of perfusionists may have been more likely to participate, potentially leading to an overestimation of the global prevalence of perfusionist involvement in ECLS management. In addition, responses were predominantly received from Europe and North America, reflecting dissemination networks and limiting the representativeness of low- and middle-income settings. Furthermore, the survey was provided only in its English version, and this might have introduced a language bias and difficulties in comparing roles due to country-level heterogeneity in professional titles. Aspects such as the effective daily worktime dedicated to ECLS management by perfusionists or training background of other personnel involved in the ECLS team were not examined in the current survey and deserves dedicated investigations. A social desirability bias in self-reporting checklists/training frequency or other aspects of the ECLS team organisation cannot be excluded. Due to the survey open dissemination, a true response rate could not be calculated. 29 However, despite a limited sample size, the number of respondents and the global scope provide valuable insights into current trends and challenges. Future studies should examine organizational aspects such as budgeting, purchasing and interprofessional collaboration and correlate staffing models with clinical outcomes to identify best practice.
Conclusions
This international survey highlights substantial heterogeneity in the training, responsibilities, and integration of perfusionists within the ECLS teams. While perfusionists continue to play a key role in circuit management, increasing collaboration with other healthcare professionals is reshaping traditional boundaries. The lack of standardized educational, training and credentialing frameworks remains a major challenge. Strengthening international cooperation and developing shared training pathways could enhance the safety, the quality and the sustainability of ECLS programs worldwide. However, further and larger studies are required to test such hypothesis.
Supplemental material
Suppplemental Material - The role of the perfusionist in the extracorporeal life support management: An international survey
Suppplemental Material for The role of the perfusionist in the extracorporeal life support management: An international survey by Cristina Scoppa, Desiree Toscano, Maria Cristina Costa, Leen Vercaemst, Gerdy Debeuckelaere, Marta Velia Antonini, Giovanni Marchetto, Mirko Belliato, Roberto Lorusso, Justyna Swol, Silvia Mariani in Perfusion
Footnotes
Acknowledgements
The authors are grateful to all colleagues worldwide for their generous participation in our survey. We thank the EuroELSO Steering and Scientific Committees for their support, survey protocol revision and final approval.
ORCID iDs
Author contributions
Cristina Scoppa: Concept/design, Data collection, Data analysis/interpretation, Statistics, Drafting article, Revision of article, Approval of article. Desiree Toscano: Concept/design, Data collection, Data analysis/interpretation, Statistics, Drafting article, Revision of article, Approval of article. Maria Cristina Costa: Concept/design, Data collection, Data analysis/interpretation, Revision of article, Approval of article. Leen Vercaemst: Concept/design, Data collection, Data analysis/interpretation, Revision of article, Approval of article. Gerdy Debeuckelaere: Concept/design, Data collection, Data analysis/interpretation, Revision of article, Approval of article. Marta Velia Antonini: Data collection, Revision of article, Approval of article. Giovanni Marchetto: Data collection, Revision of article, Approval of article. Mirko Belliato: Concept/design, Data collection, Data analysis/interpretation, Revision of article, Approval of article. Roberto Lorusso: Concept/design, Data collection, Data analysis/interpretation, Revision of article, Approval of article. Justyna Swol: Concept/design, Data collection, Data analysis/interpretation, Revision of article, Approval of article. Silvia Mariani: Concept/design, Data collection, Data analysis/interpretation, Statistics, Drafting article, Revision of article, Approval of article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
RL:consultant for Medtronic-Abiomed-LivaNova; Speaker for Abiomed; Advisory Board Member of Eurosets-Hemocue-Xenios (honoraria as research funding). JS: received honoraries from Abiomed and Getinge
Data Availability Statement
Data are available from the corresponding author upon request and with permission of EuroELSO Steering and Scientific Committee.
IRB approval
Approval of the protocol by an Ethical Committee was waived since the survey does not include patients’ data or involvement. Data were handled in accordance with the EU Directive 95/46/EC and as of 25 May 2018 in accordance with the GDPR and any other applicable data protection law.
Supplemental material
Supplemental material for this article is available online.