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Background: Although acute kidney injury (AKI) has been established as an independent risk factor for in‐hospital mortality for patients on veno‐arterial (V‐A) extracorporeal membranous oxygenation (ECMO), the impact of Kidney Disease Improving Global Outcomes (KDIGO) stages of AKI has yet to be elucidated as a risk factor. Methods: We conducted a retrospective analysis of patient outcomes based on KDIGO stages of AKI at a single institution. The analysis was a cohort of 179 patients; 66 without AKI, 19 with stage 1 AKI, 18 with stage 2 AKI, and 76 with stage 3 AKI. Results: Every 1‐year increase in age was associated with 4% increased odds of mortality at 30 days (95% confidence interval [CI] 1.01, 1.07; p = 0.004). The presence of AKI at any stage was associated with 59% increased odds of 30‐day mortality (95% CI 0.81, 3.10; p = 0.176). The presence of stage 1 AKI was associated with a 5% decreased odds of 30‐day mortality (95% CI 0.32, 2.89). The presence of stage 2 AKI (odds ratio [OR] 2.29, 95% CI 0.69, 7.55; p = 0.173) and stage 3 AKI (OR 1.68, 95% CI 0.81, 3.46; p = 0.164) was associated with increased odds of 30‐day mortality. Conclusion: Based on our single‐center study, higher KDIGO stages of AKI likely have increased odds of mortality at 30 days. Larger studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

This article discusses a case study of a 25-year-old male with sickle cell disease (SCD) who developed acute chest syndrome (ACS) and severe acute respiratory distress syndrome (ARDS). The patient was successfully treated with veno-venous extracorporeal membrane oxygenation (V-V ECMO). ACS is a common cause of ICU admission for patients with SCD, and those requiring invasive mechanical ventilation for more than 96 hours have a higher risk of mortality. The use of ECMO in patients with ACS is limited, but this case suggests that it may be a viable treatment option for severe cases. However, further research is needed to optimize ECMO candidacy and care for patients with ACS. [Extracted from the article]

Background: As the pandemic progressed, the use of extracorporeal membrane oxygenation (ECMO) for COVID‐19‐related acute respiratory distress syndrome increased, and patient triage and transfer to ECMO centers became important to optimize patient outcomes. Our objectives are to identify predictors of patient transfer for veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) evaluation as well as to describe the outcomes of accepted patients. Methods: This is a single‐center, retrospective analysis of V‐V ECMO transfer requests for adult patients with known or suspected COVID‐19 and respiratory failure from March 2020 until March 2021. Data were collected prospectively during the triage process for transfer requests as part of clinical patient care at our institution. Results: Of 341 referred patients, 112 (33%) were accepted for transfer to our facility, whereas 229 (67%) patients were declined for transfer. The Classification and Regression Tree analysis showed that patients' high pressure during airway pressure release ventilation (APRV) and age were the variables most significantly associated with the decision to accept or decline patients for transfer. Conclusions: Our triage process enabled one‐third of referred patients to be transferred for evaluation, with nearly 70% of those patients ultimately receiving ECMO support. High ventilator settings on APRV and young age were associated with acceptance for transfer. Accepted patients also had a higher incidence of adjunctive therapies (proning and paralysis) prior to transfer request, less cardiac or renal dysfunction, and a shorter duration of mechanical ventilation. Further research is warranted to investigate the outcomes of nontransferred patients. [ABSTRACT FROM AUTHOR]

Introduction: For the Veterans Health Administration (VHA) to continue to perform complex cardiothoracic surgery, there must be an established pathway for providing urgent/emergent extracorporeal life support (ECLS). Partnership with a nearby tertiary care center with such expertise may be the most resource‐efficient way to provide ECLS services to patients in post‐cardiotomy cardiogenic shock or respiratory failure. The goal of this project was to assess the efficiency, safety, and outcomes of surgical patients who required transfer for perioperative ECLS from a single stand‐alone Veterans Affairs Medical Center (VAMC) to a separate ECLS center. Methods: Cohort consisted of all cardiothoracic surgery patients who experienced cardiogenic shock or refractory respiratory failure at the local VAMC requiring urgent or emergent institution of ECLS between 2019 and 2022. The primary outcomes are the safety and timeliness of transport. Results: Mean time from the initial shock call to arrival at the ECLS center was 2.8 h. There were no complications during transfer. Six patients (86%) survived to decannulation. Conclusion: These results suggest that complex cardiothoracic surgery can be performed within the VHA system and when there is an indication for ECLS, those services can be safely and effectively provided at an affiliated, properly equipped center. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Extracorporeal membrane oxygenation (ECMO) is widely used for children treated for refractory respiratory failures or refractory cardiogenic shock. Its duration depends on organ functions recovery. Weaning is decided using macro‐circulatory tools, but microcirculation is not well evaluated. Sidestream dark‐field video imaging is used to assess the perfusion of the sublingual microvascular vessels. The aim of this study was to assess the predictive value of microcirculatory indices in ECMO weaning.This prospective monocentric study examined pediatric patients at Trousseau Hospital between March 2017 and December 2020. The study included all patients from 35 weeks of gestational age to 18 years old who were treated with ECMO. Children were divided into two groups: one with stability after weaning and the other with instability after weaning. We collected clinical and biological data, ventilation parameters, extracorporeal membrane oxygenation parameters, and drugs used at admission and after the weaning test. Microcirculations videos were taken after weaning trials with echocardiography and blood gas monitoring.The study included 30 patients with a median age of 29 days (range: 1–770 days) at admission, including 18 patients who received venoarterial ECMO (60%). There were 19 children in the stability group and 11 in the instability group. Macrocirculatory and microcirculatory indices showed no differences between groups. The microvascular flow index was subnormal in both groups (2.3 (1.8–2.4) and 2.3 (2.3–2.6), respectively; p = 0.24). The microvascular indices were similar between cases of venovenous and venoarterial ECMO and between age groups.Microcirculation monitoring at the weaning phase did not predict the failure of ECMO weaning. [ABSTRACT FROM AUTHOR]

Background: The leading causes of maternal mortality include respiratory failure, cardiovascular events, infections, and hemorrhages. The use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in the peripartum period for cardiopulmonary failure is expanding in critical care medicine. Methods: This retrospective observational study was conducted on a nationwide cohort in Israel. During the 3‐year period, between September 1, 2019, and August 31, 2022, all women in the peripartum period who had been supported by ECMO for respiratory or circulatory failure at 10 large Israeli hospitals were identified. Indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and complications were collected. Results: During the 3‐year study period, in Israel, there were 540 234 live births, and 28 obstetric patients were supported by ECMO, with an incidence of 5.2 cases per 100 000 or 1 case per 19 000 births (when excluding patients with COVID‐19, the incidence will be 2.5 cases per 100 000 births). Of these, 25 were during the postpartum period, of which 16 (64%) were connected in the PPD1, and 3 were during pregnancy. Eighteen patients (64.3%) were supported by V‐V ECMO, 9 (32.1%) by V‐A ECMO, and one (3.6%) by a VV‐A configuration. Hypoxic respiratory failure (ARDS) was the most common indication for ECMO, observed in 21 patients (75%). COVID‐19 was the cause of ARDS in 15 (53.7%) patients. The indications for the V‐A configuration were cardiomyopathy (3 patients), amniotic fluid embolism (2 patients), sepsis, and pulmonary hypertension. The maternal and fetal survival rates were 89.3% (n = 25) and 100% (n = 28). The average ECMO duration was 17.6 ± 18.6 days and the ICU stay was 29.8 ± 23.8 days. Major bleeding complications requiring surgical intervention were observed in one patient. Conclusions: The incidence of using ECMO in the peripartum period is low. The maternal and neonatal survival rates in patients treated with ECMO are high. These results show that ECMO remains an important treatment option for obstetric patients with respiratory and/or cardiopulmonary failure. [ABSTRACT FROM AUTHOR]

Background: As heart transplant guidelines evolve, the clinical indication for 73% of durable left ventricular assist device (LVAD) implants is now destination therapy. Although completely magnetically levitated LVAD devices have demonstrated improved durability relative to previous models, LVAD replacement procedures are still required for a variety of indications. Thus, the population of patients with a replaced LVAD is growing. There is a paucity of data regarding the outcomes and risk factors for those patients receiving first‐time LVAD replacements. Methods: The study cohort consisted of all consecutive patients between 2006 and 2020 that received a first‐time LVAD replacement at a single institution. Preoperative clinical and laboratory variables were collected retrospectively. The primary endpoint was death or need for an additional LVAD replacement. Data were subjected to Kaplan–Meier, univariate, and multivariate Cox hazard ratio analyses. Results: In total, 152 patients were included in the study, of which 101 experienced the primary endpoint. On multivariate analysis, patients receiving HeartMate 3 (HM3) LVADs as the replacement device showed superior outcomes (HR 0.15, 95% CI 0.065–0.35, p < 0.0001). Independent risk factors for death or need for additional replacement included preoperative extracorporeal membrane oxygenation (ECMO) (HR 4.44, 95% CI 1.87–14.45, and p = 0.00042), increased number of sternotomies (HR 5.20, 95% CI 1.87–14.45, and p = 0.0016), and preoperative mechanical ventilation (HR 1.98, 95% CI 1.01–3.86, and p = 0.045). Conclusions: Replacement with HM3 showed superior outcomes compared to all other pump types when controlling for both initial pump type and other independent predictors of death or LVAD replacement. Preoperative ECMO, mechanical ventilation, and multiple sternotomies also increased the odds for death or the need for subsequent replacement. [ABSTRACT FROM AUTHOR]

Background: Although extracorporeal membrane oxygenation (ECMO) has been used to provide temporary support for pediatric patients suffering severe respiratory or cardiac failure since 1970, ECMO systems specifically designed for pediatric patients, particularly for long‐term use, remain an unmet clinical need. We sought to develop a new pediatric ECMO system, that is, pediatric pump‐lung (PPL), consisting of a unique cylinder oxygenator with an outside‐in radial flow path and a centrifugal pump. Methods: Computational fluid dynamics was used to analyze the blood fluid field for optimized biocompatible and gas exchange performances in terms of flow characteristics, hemolysis, and gas transfer efficiency. Ovine blood was used for in vitro hemolysis and gas transfer testing. Results: Both the computational and experimental data showed that the pressure drop through the PPL's oxygenator is significantly low, even at a flow rate of more than 3.5 L/min. The PPL showed better hemolysis performance than a commercial ECMO circuit consisting of the Quadrox‐iD pediatric oxygenator and the Rotaflow pump at a 3.5 L/min flow rate and 250 mm Hg afterload pressure. The oxygen transfer rate of the PPL can reach over 200 mL/min at a flow rate of 3.5 L/min. Conclusions: The PPL has the potential to provide adequate blood pumping and excellent respiratory support with minimal risk of hemolysis for a wide range of pediatric patients. [ABSTRACT FROM AUTHOR]

Introduction: Extracorporeal membrane oxygenation (ECMO) is increasingly used for circulatory or pulmonary support not only in‐hospital but also out‐of‐hospital. Small dimensions and a lightweight design are important, especially for out‐of‐hospital use but also for intra‐hospital transportation of patients who require ECMO support. We share our first experience with the new Colibrì ECMO system. Patients and Methods: From December 2022 to January 2023, we used the new Colibrì extracorporeal circulation (ECC) system in six patients with cardiac or pulmonary failure. Results: The Colibrì system was used in‐hospital in six patients with post‐cardiac surgery low output syndrome, respiratory failure due to influenza or acute respiratory distress syndrome, cardiogenic shock, pulmonary embolism, and failed weaning from cardiopulmonary bypass. The system was implanted in venovenous (VV) and venoarterial (VA) fashion in 3 patients, respectively. In one patient, the configuration was switched from VA to VV after cardiac recovery. One patient received left‐ventricular unloading using the IMPELLA®5.5. ECMO run time was 1 to 13 days. We did not notice any ECC system‐associated complications. No ECMO system changes were required. Conclusion: Our case series concludes that the new Colibrì system is safe and effective for in‐hospital ECMO indications. The small dimensions and lightweight design are very beneficial for the transportation of patients. It might be especially helpful for out‐of‐hospital situations. [ABSTRACT FROM AUTHOR]

Background: Large Impella systems (5.0 or 5.5; i.e., Impella 5+) (Abiomed Inc., Danvers, MA, USA) help achieve better clinical outcomes through relevant left ventricular unloading in acute cardiogenic shock (CS). Here, we report our experience with Impella 5+, while focusing on the clinical outcomes depending on individual case scenarios in patients with acute CS. Methods: This single‐center retrospective observational study included 100 Impella 5+ implantations conducted on patients with acute CS from November 2018 to October 2021. After excluding 10 reimplantation cases, 90 cases were enrolled for further analysis. Results: In‐hospital and 30‐day mortality rates were 56.7% (n = 51) and 48.9% (n = 44), respectively. In‐hospital mortality was lower in patients with acute myocardial infarction (AMI) than in non‐AMI patients (p = 0.07). Young age and low lactate levels were the independent predictors of successful transition and survival after permanent mechanical circulatory support/heart transplantation (pMCS/HTX) (age, p = 0.03; lactate level, p = 0.04; survived after pMCS/HTX, n = 11; died on Impella, n = 41). During simultaneous utilization of venoarterial extracorporeal membrane oxygenation therapy and Impella 5+, termed ECMELLA therapy, high dose of noradrenaline was a predictive factor for in‐hospital mortality by multivariate analysis (n = 0.02). Conclusions: Our results suggest that enhanced Impella support might have better clinical outcomes among acute CS patients supported with large Impella, those with AMI than those with no AMI. Young age and low lactate levels were predictors of successful bridging to pMCS/HTX and favorable clinical outcomes thereafter. The clinical outcomes of ECMELLA therapy might depend on noradrenaline dose at the time of Impella 5+ implantation. [ABSTRACT FROM AUTHOR]

Background: Bleeding and thrombosis are common extracorporeal membrane oxygenation (ECMO) complications associated with increased mortality. Heparin is the most commonly used ECMO anticoagulant, employed in 94% of cases. Reduced antithrombin III (AT3) levels could decrease heparin effectiveness. Neonates have inherently lower levels of AT3 than adults, and pediatric patients on ECMO can develop AT3 deficiency. One potential approach for patients on ECMO with AT3 deficiency is exogenous AT3 supplementation. However, there is conflicting data concerning the use of AT3 for pediatric and neonatal patients on ECMO. Methods: We analyzed the Bleeding and Thrombosis during ECMO database of 514 neonatal and pediatric patients on ECMO. We constructed daily regression models to determine the association between AT3 supplementation and rates of bleeding and thrombosis. Given the physiological differences between pediatric patients and neonates, we constructed separate models for each. Results: AT3 administration was associated with increased rates of daily bleeding among pediatric (adjusted odds ratio [aOR] 1.59, p < 0.01) and neonatal (aOR 1.37, p = 0.04) patients. AT3 supplementation did not reduce the rate of thrombosis for either pediatric or neonatal patients. Conclusion: AT3 administration was associated with increased rates of daily bleeding, a hypothesized potential complication of AT3 supplementation. In addition, AT3 supplementation did not result in lower rates of thrombosis. We recommend clinicians utilize caution when considering supplementing patients on ECMO with exogenous AT3. [ABSTRACT FROM AUTHOR]

Background: Assessing the outcome of Veno‐Venous Extracorporeal Membrane Oxygenation (V‐V ECMO) support remains challenging as plasma lactate (pLA), the widely used tool for this purpose, has been shown unreliable. We hypothesized that plasma oncostatin M (pOSM), a sensitive marker of leukocyte activation in infection and inflammation, could address this deficiency. Methods: Plasma OSM levels were measured by ELISA in 30 Acute Respiratory Distress Syndrome (ARDS) patients, prior to cannulation (baseline) and decannulation. Results: Based on the absolute pOSM levels at presentation, patients were separated into two groups, A and B. Patients in group A had low pOSM levels (Mean ± SD; Median, 1.1 ± 3.8; 0 pg/mL), whereas group B had high pOSM levels (1548 ± 1999; 767 pg/mL) [t‐test: p < 0.01]. The percentage of pOSM levels at decannulation relative to baseline OSM levels was significantly higher in those who died (116.8 ± 68.0; 85.3%) than those who survived (47.6 ± 25.5; 48.9%) [t‐test: p = 0.02; Mann–Whitney U Test: p = 0.01]. Conversely, no significant difference was observed in the percentage of pLA levels between those who died (142.9 ± 179.9; 89.8%) and those who survived (79.3 ± 34.3; 81.8%) [t‐test: p = 0.31; Mann–Whitney U Test: p = 0.63]. Conclusion: These early findings suggested critical value of absolute and relative pOSM to characterize the inflammatory burden of ARDS patients and the outcome of their V‐V ECMO support. [ABSTRACT FROM AUTHOR]

Background: Thrombosis remains a critical complication during venovenous extracorporeal membrane oxygenation (VV ECMO). The involvement of neutrophil extracellular traps (NETs) in thrombogenesis has to be discussed. The aim was to verify NETs in the form of cell‐free DNA (cfDNA) in the plasma of patients during ECMO. Methods: A fluorescent DNA‐binding dye (QuantifFluor®, Promega) was used to detect cell‐free DNA in plasma samples. cfDNA concentrations from volunteers (n = 21) and patients (n = 9) were compared and correlated with clinical/technical data before/during support, ECMO end and time of a system exchange. Results: Before ECMO, patients with a median (IQR) age of 59 (51/63) years, SOFA score of 11 (10/15), and ECMO run time of 9.0 (7.0/19.5) days presented significantly higher levels of cfDNA compared to volunteers (6.4 (5.8/7.9) ng/μL vs. 5.9 (5.4/6.3) ng/μL; p = 0.044). Within 2 days after ECMO start, cfDNA, inflammatory, and hemolysis parameters remained unchanged, while platelets decreased (p = 0.005). After ECMO removal at the end of therapy, cfDNA, inflammation, and coagulation data (except antithrombin III) remained unchanged. The renewal of a system resulted in known alterations in fibrinogen, d‐dimers, and platelets, while cfDNA remained unchanged. Conclusion: Detection of cfDNA in plasma of ECMO patients was not an indicator of acute and circuit‐induced thrombogenesis. [ABSTRACT FROM AUTHOR]

Background: Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients. Methods: This is a retrospective observational single‐center study. Results: Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V‐V ECMO support over an 8‐year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration [25.5 (17.3–40.1) vs 37.2 (26.5–53.2) days, p = 0.013] and a shorter ECMO‐to‐tracheostomy time [13.3 (8.5–19.7) vs 27.8 (16.3–36.9) days, p < 0.001] compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (p = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (p = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (p < 0.001) and a shorter duration of V‐V ECMO support (p < 0.001). Our series includes 24 patients affected by COVID‐19, who did not show significantly higher rates of major bleeding when compared to non‐COVID‐19 patients (p = 0.297). Within the COVID‐19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (p = 1.0). Conclusions: Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID‐19 patients, if relevant clinical expertise is available. [ABSTRACT FROM AUTHOR]

Background: Pulmonary complications often occur in patients receiving veno‐arterial extracorporeal membrane oxygenation (VA ECMO). However, the prognostic impact of lung damage has not been fully elucidated. Methods: This single‐center retrospective observational study targeted patients with cardiogenic shock who received VA ECMO between 2012 and 2021. This study included 65 patients who underwent chest computed tomography (CT) on VA ECMO, followed by escalation to central mechanical circulatory support (MCS) with left ventricular venting. The average density of lung CT images was measured using region‐of‐interest methods, and the primary endpoint was 180‐day all‐cause death after escalation to the central MCS. Results: Twenty‐two patients (34%) developed 180‐day all‐cause death. According to the Cox regression analysis, age (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.03–1.14; p = 0.001), ischemic etiology (HR, 5.53; 95% CI, 2.09–14.62; p < 0.001), duration of VA ECMO support (HR, 1.19; 95% CI, 1.00–1.40; p = 0.045), and lung CT density (≥ −481 Hounsfield unit [HU]) (HR, 6.33; 95% CI, 2.26–17.72; p < 0.001) were independently associated with all‐cause death. Receiver operating characteristic curve analysis determined that lung CT density ≥ −481 HU is an optimal cutoff value for predicting all‐cause death (area under the curve [AUC], 0.72). The 180‐day overall survival rate for patients with high lung CT density (≥ −481 HU) was significantly lower than that for those with low lung CT density (< −481 HU) (44.4% vs. 81.6%, respectively, p = 0.002). Conclusions: Higher lung CT density could be a useful predictor of death in patients with VA ECMO requiring central MCS escalation. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal life support (ECLS) for status asthmaticus (SA) is rare. Increased safety and experience may increase utilization of ECLS for SA. Methods: We reviewed pediatric (<18 years old) patients requiring ECLS for SA between 1998 and 2019 within the Extracorporeal Life Support Organization (ELSO) Registry and Nemours Children's Health (NCH) system. We compared patient characteristics, pre‐ECLS medications, clinical data, complications, and survival to discharge between Early (1988–2008) and Late (2009–2019) eras. Results: From the ELSO Registry, we identified 173 children, 53 in Early and 120 in Late eras, with primary diagnosis of SA. Pre‐ECLS hypercarbic respiratory failure was similar between eras (median pH 7.0 and pCO2 111 mm Hg). Venovenous mode (79% vs. 82%), median ECLS time (116 vs. 99 h), time to extubation (53 vs. 62 h), and hospital survival (89% vs. 88%) also remained similar. Intubation to cannulation time significantly decreased (20 vs. 10 h, p = 0.01). ECLS without complication occurred more in the Late era (19% vs. 39%, p < 0.01), with decreased hemorrhagic (24% vs. 12%, p = 0.05) and noncannula‐related mechanical (19% vs. 6%, p = 0.008) complications. Within NCH, we identified six Late era patients. Pre‐ECLS medication favored intravenous beta agonists, bronchodilators, magnesium sulfate, and steroids. One patient died from neurological complications following pre‐ECLS cardiac arrest. Conclusions: Collective experience supports ECLS as a rescue therapy for pediatric SA. Survival to discharge remains good, and complication rates have improved. Pre‐ECLS cardiac arrest may potentiate neurologic injury and impact survival. Further study is needed to evaluate causal relationships between complications and outcomes. [ABSTRACT FROM AUTHOR]

Background: Veno‐arterial–venous extracorporeal membrane oxygenation (V‐AV ECMO) is a less commonly used configuration of ECMO. We sought to understand the indications, utilization patterns, and outcomes of V‐AV ECMO by quantitatively pooling the existing evidence from the literature. Methods: Electronic search was performed to identify all relevant studies reporting V‐AV ECMO usage. Five studies comprising 77 patients were selected and cohort‐level data were extracted for further analysis. Results: Mean patient age was 61 (95% CI: 55.2, 66.5) years and 30% (23/77) were female. The majority of cases [91% (70/77)] were transitioned to V‐AV ECMO from another pre‐existing ECMO configuration: V‐A ECMO in 55% (42/77) vs. V‐V ECMO in 36% (28/77), p = 0.04. Only 9% (7/77) of cases were directly placed on V‐AV ECMO. The mean duration of hospital stay was 42.3 (95% CI: 10.5, 74.2) days, while ICU mortality was 46% (29, 64). Transition to durable left ventricular assist device was performed in 3% (2/64) of patients, while 3% (2/64) underwent heart transplantation. V‐AV ECMO was successfully weaned to explantation in 33% (21/64) of patients. Conclusion: V‐AV ECMO is a viable option for optimizing cardiopulmonary support in selected patients. Survival to weaning or bridging therapy appears comparable to more common ECMO configurations. [ABSTRACT FROM AUTHOR]

Background: Mobilization is important in longer courses in intensive care unit (ICU), typical for patients requiring venovenous extracorporeal membrane oxygenation (V‐V ECMO). For patients supported with ECMO, especially out‐of‐bed mobilizations improve outcome. We hypothesized that utilization of a dual lumen cannula (DLC) for V‐V ECMO would facilitate out‐of‐bed mobilization compared to single lumen cannulas (SLC). Methods: Retrospective single center registry study including all V‐V ECMO patients cannulated between 10/2010 and 05/2021 for respiratory failure. Results: The registry included 355 V‐V ECMO patients (median age 55.6 years, 31.8% female, 27.3% with preexisting pulmonary disease), 289/355 (81.4%) primary cannulated with DLC, and 66/355 (18.6%) using SLC. Both groups had similar pre‐ECMO characteristics. The runtime of the first ECMO cannula was significantly longer in DLC compared to SLC (169 vs. 115 h, p = 0.015). The frequency of prone positioning during V‐V ECMO was similar in both groups (38.4 vs. 34.8%, p = 0.673). There was no difference in in‐bed mobilization (41.2 vs. 36.4%, for DLC and SLC, respectively, p = 0.491). Patients with DLC were more often mobilized out‐of‐bed (25.6 vs. 12.1%, OR 2.495 [95% CI 1.150 to 5.268], for DLC and SLC, respectively, p = 0.023). Hospital survival was similar in both groups (46.4 vs. 39.4%, for DLC and SLC, respectively, p = 0.339). Conclusion: Patients cannulated with a dual lumen cannula for V‐V ECMO support were significantly more often mobilized out‐of‐bed. Since mobilization is important in prolonged ICU courses typical for ECMO patients, this might be an important benefit. Other benefits of DLC were the longer runtime of the initial cannula set and fewer suction events. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal life support (ECLS) has extensive applications in managing patients with acute cardiac and pulmonary failure. Two primary modalities of ECLS, cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO), include several similarities in their composition, complications, and patient outcomes. Both CPB and ECMO pose a high risk of thrombus formation and platelet activation due to the large surface area of the devices and bleeding due to system anticoagulation. Therefore, novel methods of anticoagulation are needed to reduce the morbidity and mortality associated with extracorporeal support. Nitric oxide (NO) has potent antiplatelet properties and presents a promising alternative or addition to anticoagulation with heparin during extracorporeal support. Methods: We developed two ex vivo models of CPB and ECMO to investigate NO effects on anticoagulation and inflammation in these systems. Results: Sole addition of NO as an anticoagulant was not successful in preventing thrombus formation in the ex vivo setups, therefore a combination of low‐level heparin with NO was used. Antiplatelet effects were observed in the ex vivo ECMO model when NO was delivered at 80 ppm. Platelet count was preserved after 480 min when NO was delivered at 30 ppm. Conclusion: Combined delivery of NO and heparin did not improve haemocompatibility in either ex vivo model of CPB and ECMO. Anti‐inflammatory effects of NO in ECMO systems have to be evaluated further. [ABSTRACT FROM AUTHOR]

Background: High‐quality evidence for post‐cardiotomy extracorporeal life support (PC‐ECLS) management is lacking. This study investigated real‐world PC‐ECLS clinical practices. Methods: This cross‐sectional, multi‐institutional, international pilot survey explored center organization, anticoagulation management, left ventricular unloading, distal limb perfusion, PC‐ECLS monitoring, and transfusion practices. Twenty‐nine questions were distributed among 34 hospitals participating in the Post‐cardiotomy Extra‐Corporeal Life Support Study. Results: Of the 32 centers [16 low‐volume (50%); 16 high‐volume (50%)] that responded, 16 (50%) had dedicated ECLS specialists. Twenty‐six centers (81.3%) reported using additional mechanical circulatory supports. Anticoagulation practices were highly heterogeneous: 24 hospitals (75%) reported using patients bleeding status as a guide, without a specific threshold in 54.2% of cases. Transfusion targets ranged from 7 to 10 g/dL. Most centers used cardiac venting on a case‐by‐case basis (78.1%) and regular distal limb perfusion (84.4%). Nineteen (54.9%) centers reported dedicated monitoring protocols, including daily echocardiography (87.5%), Swan‐Ganz catheterization (40.6%), cerebral near‐infrared spectroscopy (53.1%), and multimodal assessment of limb ischemia. Inspection of the circuit (71.9%), oxygenator pressure drop (68.8%), plasma free hemoglobin (75%), d‐dimer (59.4%), lactate dehydrogenase (56.3%), and fibrinogen (46.9%) are used to diagnose hemolysis and thrombosis. Conclusions: This study shows remarkable heterogeneity in clinical practices for PC‐ECLS management. More standardized protocols and better implementation of the available evidence are recommended. [ABSTRACT FROM AUTHOR]

Background: Patients with refractory cardiogenic shock from an acute myocardial infarction may receive percutaneous coronary intervention (PCI) and require the use of venoarterial extracorporeal membrane oxygenation (VA–ECMO). The purpose of this study was to compare bleeding and thrombotic events in patients treated with cangrelor plus aspirin versus oral dual antiplatelet therapy (DAPT) while supported with VA–ECMO. Methods: We conducted a retrospective review of patients who received PCI, were supported with VA–ECMO, and were treated with either cangrelor plus aspirin or oral DAPT from February 2016 through May 2021 at Allegheny General Hospital. The primary objective was the incidence of major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or greater. The incidence of thrombotic events was a secondary objective. Results: Thirty‐seven patients were included, 19 in the cangrelor plus aspirin group, and 18 in the oral DAPT group. All the patients in the cangrelor group received a dose of 0.75 mcg/kg/min. Major bleeding occurred in 7 patients (36.8%) in the cangrelor group compared to 7 patients (38.9%) in the oral DAPT group (p = 0.90). No patient developed stent thrombosis. Two patients (10.5%) in the cangrelor group had a thrombotic event versus 3 patients (16.7%) in the oral DAPT group (p = 0.66). Conclusions: Bleeding and thrombotic events were comparable between patients receiving cangrelor plus aspirin versus oral DAPT while on VA–ECMO. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) is a recognized method of support in patients with severe and refractory acute respiratory distress syndrome (ARDS) caused by SARS‐CoV‐2 infection. While veno‐venous (VV) ECMO is the most common type, some patients with severe hypoxemia may require modifications to the ECMO circuit. In this study, we aimed to investigate the effects of adding a second drainage cannula to the circuit in patients with refractory hypoxemia, on their gas exchange, mechanical ventilation, ECMO settings, and clinical outcomes. Methods: We conducted an observational retrospective study based on a single‐center institutional registry including all consecutive cases of COVID‐19 patients requiring ECMO admitted to the Centre of Extracorporeal Therapies in Warsaw between March 1, 2020 and March 1, 2022. We selected patients who had an additional drainage cannula inserted. Changes in ECMO and ventilator settings, blood oxygenation, and hemodynamic parameters, as well as clinical outcomes were assessed. Results: Of 138 VV ECMO patients, 12 (9%) patients met the inclusion criteria. Ten patients (83%) were men, and mean age was 42.2 ± 6.8. An addition of drainage cannula resulted in a significant raise in ECMO blood flow (4.77 ± 0.44 to 5.94 ± 0.81 [L/min]; p = 0.001), and the ratio of ECMO blood flow to ECMO pump rotations per minute (RPM), whereas the raise in ECMO RPM alone was not statistically significant (3432 ± 258 to 3673 ± 340 [1/min]; p = 0.064). We observed a significant drop in ventilator FiO2 and a raise in PaO2 to FiO2 ratio, while blood lactates did not change significantly. Nine patients died in hospital, one was referred to lung transplantation center, two were discharged uneventfully. Conclusions: The use of an additional drainage cannula in severe ARDS associated with COVID‐19 allows for an increased ECMO blood flow and improved oxygenation. However, we observed no further improvement in lung‐protective ventilation and poor survival. [ABSTRACT FROM AUTHOR]

Background: Veno‐venous extracorporeal membrane oxygenation (V‐V ECMO) is a lifesaving support modality for severe respiratory failure, but its resource‐intensive nature led to significant controversy surrounding its use during the COVID‐19 pandemic. We report the performance of several ECMO mortality prediction and severity of illness scores at discriminating survival in a large COVID‐19 V‐V ECMO cohort. Methods: We validated ECMOnet, PRESET (PREdiction of Survival on ECMO Therapy‐Score), Roch, SOFA (Sequential Organ Failure Assessment), APACHE II (acute physiology and chronic health evaluation), 4C (Coronavirus Clinical Characterisation Consortium), and CURB‐65 (Confusion, Urea nitrogen, Respiratory Rate, Blood Pressure, age >65 years) scores on the ISARIC (International Severe Acute Respiratory and emerging Infection Consortium) database. We report discrimination via Area Under the Receiver Operative Curve (AUROC) and Area under the Precision Recall Curve (AURPC) and calibration via Brier score. Results: We included 1147 patients and scores were calculated on patients with sufficient variables. ECMO mortality scores had AUROC (0.58–0.62), AUPRC (0.62–0.74), and Brier score (0.286–0.303). Roch score had the highest accuracy (AUROC 0.62), precision (AUPRC 0.74) yet worst calibration (Brier score of 0.3) despite being calculated on the fewest patients (144). Severity of illness scores had AUROC (0.52–0.57), AURPC (0.59–0.64), and Brier Score (0.265–0.471). APACHE II had the highest accuracy (AUROC 0.58), precision (AUPRC 0.64), and best calibration (Brier score 0.26). Conclusion: Within a large international multicenter COVID‐19 cohort, the evaluated ECMO mortality prediction and severity of illness scores demonstrated inconsistent discrimination and calibration highlighting the need for better clinically applicable decision support tools. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal organ assist devices provide lifesaving functions for acutely and chronically ill patients suffering from respiratory and renal failure, but their availability and use is severely limited by an extremely high level of operational complexity. While current hollow fiber‐based devices provide high‐efficiency blood gas transfer and waste removal in extracorporeal membrane oxygenation (ECMO) and hemodialysis, respectively, their impact on blood health is often highly deleterious and difficult to control. Further challenges are encountered when integrating multiple organ support functions, as is often required when ECMO and ultrafiltration (UF) are combined to deal with fluid overload in critically ill patients, necessitating an unwieldy circuit containing two separate cartridges. Methods: We report the first laboratory demonstration of simultaneous blood gas oxygenation and fluid removal in single microfluidic circuit, an achievement enabled by the microchannel‐based blood flow configuration of the device. Porcine blood is flowed through a stack of two microfluidic layers, one with a non‐porous, gas‐permeable silicone membrane separating blood and oxygen chambers, and the other containing a porous dialysis membrane separating blood and filtrate compartments. Results: High levels of oxygen transfer are measured across the oxygenator, while tunable rates of fluid removal, governed by the transmembrane pressure (TMP), are achieved across the UF layer. Key parameters including the blood flow rate, TMP and hematocrit are monitored and compared with computationally predicted performance metrics. Conclusions: These results represent a model demonstration of a potential future clinical therapy where respiratory support and fluid removal are both realized through a single monolithic cartridge. [ABSTRACT FROM AUTHOR]

Introduction: In cardiac arrest, cerebral ischemia and reperfusion injury mainly determine the neurological outcome. The aim of this study was to investigate the relation between the course of cerebral oxygenation and regain of consciousness in patients treated with extracorporeal cardiopulmonary resuscitation (ECPR). We hypothesized that rapid cerebral oxygenation increase causes unfavorable outcomes. Methods: This prospective observational study was conducted in three European hospitals. We included adult ECPR patients between October 2018 and March 2020, in whom cerebral regional oxygen saturation (rSO2) measurements were started minutes before ECPR initiation until 3 h after. The primary outcome was regain of consciousness, defined as following commands, analyzed using binary logistic regression. Results: The sample consisted of 26 ECPR patients (23% women, Agemean 46 years). We found no significant differences in rSO2 values at baseline (49.1% versus 49.3% for regain versus no regain of consciousness). Mean cerebral rSO2 values in the first 30 min after ECPR initiation were higher in patients who regained consciousness (38%) than in patients who did not regain consciousness (62%, odds ratio 1.23, 95% confidence interval 1.01–1.50). Conclusion: Higher mean cerebral rSO2 values in the first 30 min after initiation of ECPR were found in patients who regained consciousness. [ABSTRACT FROM AUTHOR]

Objectives: To perform a systematic review and meta‐analysis of the techniques and outcomes associated with percutaneous decannulation of venoarterial extracorporeal membrane oxygenation (VA–ECMO) using the Manta vascular closure device. Background: Peripheral VA–ECMO can be used to treat critically ill patients with conditions such as refractory cardiogenic shock. After percutaneous implantation of VA–ECMO, VA–ECMO can also be decannulated completely percutaneously by using a vascular closure device. The Manta vascular closure device is a dedicated device used in the closure of large‐bore arteriotomies by sandwiching the arteriotomy with an intra‐arterial toggle and an extraluminal collagen plug. Methods: We performed a thorough literature search using various electronic databases. We included studies that reported outcomes after peripheral femorofemoral VA–ECMO decannulation with the Manta vascular closure device. We performed a meta‐analysis of proportions on outcome measures, including technical success, bleeding complications, vascular complications, wound complications, major amputation, and procedural‐related deaths. Results: We included seven studies with a total of 116 patients. The overall technical success of percutaneous decannulation of VA–ECMO with the Manta vascular closure device was 93.7%. The overall incidence of bleeding, vascular and wound complications was 1.7%, 13.8%, and 3.4%, respectively. No patient required lower limb amputation or died due to VA–ECMO decannulation. Conclusion: Percutaneous decannulation with the Manta vascular closure device is an effective and safe procedure that should be considered in suitable patients on VA–ECMO. [ABSTRACT FROM AUTHOR]

Background: Little is known about safety and efficacy of the use of Impella 5.5 compared to previous iterations in the setting of Impella with Veno‐Arterial Extracorporeal Membrane Oxygenation Support as ECPELLA. Methods: Consecutive patients who were treated by ECPELLA with surgically implanted axillary Impella 5.5 (N = 13) were compared with patients supported by ECPELLA with percutaneous femoral Impella CP or 2.5 (Control, N = 13). Results: The total ECPELLA flow was higher in ECPELLA 5.5 group (6.9 vs. 5.4 L/min, p = 0.019). Actual hospital survival was higher than predicted and comparable in both groups (ECPELLA 5.5, 61.5% vs. Control, 53.8%, p = 0.691). Both total device complications (ECPELLA 5.5, 7.7% vs. Control, 46.1%, p = 0.021) and Impella‐specific complications (ECPELLA 5.5, 0% vs. Control, 30.8%, p = 0.012) were significantly lower in the ECPELLA 5.5 group. Conclusions: Utilization of Impella 5.5 in the setting of ECPELLA provides greater hemodynamic support with a lower risk of complications compared to Impella CP or 2.5. [ABSTRACT FROM AUTHOR]

Background: Post‐acute myocardial infarction papillary muscle rupture (post‐AMI PMR) may present variable clinical scenarios and degree of emergency due to result of cardiogenic shock. Veno‐arterial extracorporeal life support (V‐A ECLS) has been proposed to improve extremely poor pre‐ or postoperative conditions. Information in this respect is scarce. Methods: From the CAUTION (meChanical complicAtion of acUte myocardial infarcTion: an InternatiOnal multiceNter cohort study) database (16 different Centers, data from 2001 to 2018), we extracted adult patients who were surgically treated for post‐AMI PMR and underwent pre‐ or/and postoperative V‐A ECLS support. The end‐points of this study were in‐hospital survival and ECLS complications. Results: From a total of 214 post‐AMI PMR patients submitted to surgery, V‐A ECLS was instituted in 23 (11%) patients. The median age was 61.7 years (range 46–81 years). Preoperatively, ECLS was commenced in 10 patients (43.5%), whereas intra/postoperative in the remaining 13. The most common V‐A ECLS indication was post‐cardiotomy shock, followed by preoperative cardiogenic shock and cardiac arrest. The median duration of V‐A ECLS was 4 days. V‐A ECLS complications occurred in more than half of the patients. Overall, in‐hospital mortality was 39.2% (9/23), compared to 22% (42/219) for the non‐ECLS group. Conclusions: In post‐AMI PMR patients, V‐A ECLS was used in almost 10% of the patients either to promote bridge to surgery or as postoperative support. Further investigations are required to better evaluate a potential for increased use and its effects of V‐A ECLS in such a context based on the still high perioperative mortality. [ABSTRACT FROM AUTHOR]

Background: Controlled donation after circulatory determination of death (cDCD) seems an effective way to mitigate the critical shortage of available organs for transplant worldwide. As a recently developed procedure for organ retrieval, some questions remain unsolved such as the uncertainty regarding the effect of functional warm ischemia time (FWIT) on organs´ viability. Methods: We developed a multicenter prospective cohort study collecting all data from evaluated organs during cDCD from 2017 to 2020. All the procedures related to cDCD were performed with normothermic regional perfusion. The analysis included organ retrieval as endpoint and FWIT as exposure of interest. The effect of FWIT on the likelihood for organ retrieval was evaluated with Relative distribution analysis. Results: A total amount of 507 organs´ related information was analyzed from 95 organ donors. Median donor age was 62 years, and 63% of donors were male. Stroke was the most common diagnosis before withdrawal of life‐sustaining therapy (61%), followed by anoxic encephalopathy (21%). This analysis showed that length of FWIT was inversely associated with organ retrieval rates for liver, kidneys, and pancreas. No statistically significant association was found for lungs. Conclusions: Results showed an inverse association between functional warm ischemia time (FWIT) and retrieval rate. We also have postulated optimal FWIT's thresholds for organ retrieval. FWIT for liver retrieval remained between 6 and less than 11 min and in case of kidneys and pancreas, the optimal FWIT for retrieval was 6 to 12 min. These results could be valuable to improve organ utilization and for future analysis. [ABSTRACT FROM AUTHOR]

Background: Extubation strategy in extracorporeal life support patients remains unclear, and literature only reports studies with significant biases. Objectives: To explore the prognostic impact of an early ventilator‐weaning strategy in assisted patients after controlling for confounding factors. Methods: A 10‐year retrospective study included 241 patients receiving extracorporeal life support for at least 48 h, corresponding to a total of 977 days spent on assistance. The a priori probability of extubation for each day of assistance was calculated according to daily biological examinations, drug doses, clinical observations, and admission data to pair each day containing an extubation with one on which the patient was not extubated. The primary outcome was survival at day 28. The secondary outcomes were survival at day 7, respiratory infections, and safety criteria. Results: Two similar cohorts of 61 patients were generated. Survival at day 28 was better in patients extubated under assistance in univariate and multivariate (HR = 0.37 [0.2–0.68], p‐value = 0.002) analyses. Patients who underwent failed early extubation did not have a different prognosis from those without early extubation. Successful early extubation was associated with a better outcome than a failed or no attempt at early extubation. Survival at day 7 and the rate of respiratory infections were better in early‐extubated patients. Safety data did not differ between the two groups. Conclusions: Early extubation during assistance was associated with a superior outcome in our propensity‐matched cohort study. The safety data were reassuring. However, due to the lack of prospective randomized studies, the causality remains uncertain. [ABSTRACT FROM AUTHOR]

Objective: Pulsatile‐flow veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) has shown encouraging results for microcirculation resuscitation and left ventricle unloading in patients with refractory cardiogenic shock. We aimed to comprehensively assess different V‐A ECMO parameters and their contribution to hemodynamic energy production and transfer through the device circuit. Methods: We used the i‐cor® ECMO circuit, which composed of Deltastream DP3 diagonal pump and i‐cor® console (Xenios AG), the Hilite 7000 membrane oxygenator (Xenios AG), venous and arterial tubing and a 1 L soft venous pseudo‐patient reservoir. Four different arterial cannulae (Biomedicus 15 and 17 Fr, Maquet 15 and 17 Fr) were used. For each cannula, 192 different pulsatile modes were investigated by adjusting flow rate, systole/diastole ratio, pulsatile amplitudes and frequency, yielding 784 unique conditions. A dSpace data acquisition system was used to collect flow and pressure data. Results: Increasing flow rates and pulsatile amplitudes were associated with significantly higher hemodynamic energy production (both p < 0.001), while no significant associations were seen while adjusting systole‐to‐diastole ratio (p = 0.73) or pulsing frequency (p = 0.99). Arterial cannula represents the highest resistance to hemodynamic energy transfer with 32%–59% of total hemodynamic energy generated being lost within, depending on pulsatile flow settings used. Conclusions: Herein, we presented the first study to compare hemodynamic energy production with all pulsatile ECLS pump settings and their combinations and widely used yet previously unexamined four different arterial ECMO cannula. Only increased flow rate and amplitude increase hemodynamic energy production as single factors, whilst other factors are relevant when combined. [ABSTRACT FROM AUTHOR]

Background: Venoarterial extracorporeal membrane oxygenation (VA‐ECMO) has been widely used in high‐risk acute myocardial infarction (AMI) patients with promising outcomes. However, the underlying molecular mechanisms remain unknown and a VA‐ECMO animal model has not yet been established. The purpose of this study was to establish a VA‐ECMO model in AMI rats and evaluate long‐term cardiac function. Methods: We first established AMI in 20 Sprague–Dawley (SD) rats by ligating the left anterior descending coronary artery, while five rats underwent a thoracotomy to form the sham group. VA‐ECMO was established after 30mins of AMI in 10 rats through the right jugular vein for venous drainage and right femoral artery for arterial infusion. Arterial blood pressure was monitored using a catheter in the left femoral artery, blood gas parameters were measured using a blood gas analyzer, while myocardial enzymes were detected using an ELISA Kit. Cardiac function was assessed through echocardiography on day 15. Masson staining and Western Blot were used for evaluating myocardial fibrosis, while histological injury was evaluated using hematoxylin and eosin staining. Results: VA‐ECMO support stabilized blood pressure, decreased the levels of myocardial enzymes including cTnI, cTnT, CK‐MB, and was associated with a higher survival rate. In the long term, the VA‐ECMO group showed improved cardiac function, significantly increased EF and FS but significantly decreased EDV and ESV compared to the AMI group. Furthermore, VA‐ECMO significantly alleviated pathological damage and myocardial fibrosis. Conclusion: We established an economical, reliable, and reproducible VA‐ECMO animal model in AMI rats, and demonstrated that VA‐ECMO support prevents deteriorated cardiac function. [ABSTRACT FROM AUTHOR]

Globalization in Asia and consequent strengthening of healthcare economic factors in tandem with an increasing heart failure (HF) population have enhanced potential for development and progress in the fields of HF medicine and mechanical circulatory support (MCS). In Japan, there are unique opportunities to investigate the outcome of acute and chronic MCS and a national registry for percutaneous and implantable left ventricular assist device (LVAD) including Impella pumps has been established. A Peripheral extracorporeal membrane oxygenation (ECMO) for acute MCS has been used in more than 7000 patients annually and Impella usage in more than 4000 patients over the past 4 years was noted. Recently, a novel centrifugal pump with hydrodynamically levitated impeller was developed and approved for mid‐term extracorporeal circulatory support. In terms of chronic MCS more than 1200 continuous flow LVADs have been implanted during the past decade, and 2‐year survival rate after primary LVAD implantation is 91%. Because of donor organ shortage, more than 70% of heart transplant recipients required LVAD support for more than 3 years and prevention and treatment of complications during long‐term LVAD support have become important. Five important topics including hemocompatibility‐related complications, LVAD infections, aortic valve insufficiency, right ventricular failure and cardiac recovery during LVAD support are discussed in this review for improving clinical outcomes. Findings from Japan will continue to provide useful information regarding MCS for the Asia‐Pacific region and beyond. [ABSTRACT FROM AUTHOR]

Background: The criteria for the selection of COVID‐19 patients that could benefit most from ECMO organ support are yet to be defined. In this study, we evaluated the predictive performance of ECMO mortality predictive models in patients with COVID‐19. We also performed a cost–benefit analysis depending on the mortality predicted probability. We conducted a retrospective cohort study in COVID‐19 patients who received ECMO at two tertiary care hospitals between March 2020 to July 2021. Materials and Methods: We evaluated the discrimination (C‐statistic), calibration (Cox calibration), and accuracy of the prediction of death due to severe ARDS in V‐V ECMO score (PRESERVE), the Respiratory Extracorporeal Membrane Oxygenation Survival Score (RESP) score, and the PREdiction of Survival on ECMO Therapy‐Score (PRESET) score. In addition, we compared the RESP score with Plateau pressure instead of Peak pressure. Results: We included a total of 36 patients, 29 (80%) of them male and with a median (IQR) APACHE of 10 (8–15). The PRESET score had the highest discrimination (AUROCs 0.81 [95%CI 0.67–0.94]) and calibration (calibration‐in‐the‐large 0.5 [95%CI −1.4 to 0.3]; calibration slope 2.2 [95%CI 0.7/3.7]). The RESP score with Plateau pressure had higher discrimination than the conventional RESP score. The cost per QALY in the USA, adjusted to life expectancy, was higher than USD 100 000 in patients older than 45 years with a PRESET > 10. Conclusion: The PRESET score had the highest predictive performance and could help in the selection of patients that benefit most from this resource‐demanding and highly invasive organ support. [ABSTRACT FROM AUTHOR]

Purpose: Managing acute respiratory distress syndrome (ARDS) patients on venovenous extracorporeal membrane oxygenation (V‐V ECMO), without sedation/neuromuscular blockade to allow physical and occupational therapy (PT/OT) participation, is untraditional. Here, we investigate the impact of early PT/OT initiation on discharge functional activity for ARDS patients managed on V‐V ECMO. Methods: This is a retrospective review of 67 ARDS patients managed with V‐V ECMO at a single academic center from February 2018 to June 2021. Data collected included patient characteristics, days of V‐V ECMO support, day of PT/OT initiation, and ambulation distance and Activity Measure for Post‐Acute Care (AMPAC) Six‐Clicks score on day of discharge. Results: Patients with >7 days of V‐V ECMO support had decreased ambulation and AMPAC scores compared to those with <7 days (70.5 vs. 162.1, p < 0.01 and 12.3 vs. 16.4, p = 0.01, respectively). PT/OT initiation within 7 days after starting V‐V ECMO significantly improved ambulation and AMPAC scores (163.5 vs. 59.5, p < 0.001, and 16.6 vs. 11.8, p < 0.01, respectively). Additionally, in patients with >7 days of V‐V ECMO support, those who began PT/OT within 8 days of V‐V ECMO cannulation had significantly improved ambulation and AMPAC scores (151.8 vs. 44.2, p < 0.01, and 16.5 vs. 11.0, p < 0.01, respectively). Conclusion: Early PT/OT initiation in severe ARDS patients managed on V‐V ECMO is associated with improved patient functional activity on day of discharge. Our study further supports the use of V‐V ECMO in treatment of severe ARDS without sedation/neuromuscular blockade and specifically demonstrates PT/OT should be started early following V‐V ECMO cannulation. [ABSTRACT FROM AUTHOR]

The use of veno‐arterial extracorporeal membrane oxygenation as extracorporeal cardiopulmonary resuscitation in patients suffering out‐of‐hospital cardiac arrest, largely increased in the last decade despite evidence supporting this practice being limited to non‐randomized studies. However, between 2020 and 2023, four randomized studies were published comparing extracorporeal cardiopulmonary resuscitation to conventional cardiopulmonary resuscitation with controversial findings that triggered great debates. In this controversy, we discuss merits and pitfalls, and provide a critical interpretation of the available evidence from randomized trials on the use of extracorporeal cardiopulmonary resuscitation, with a particular focus on the recent multi‐center INCEPTION trial. [ABSTRACT FROM AUTHOR]

Background: In adults with refractory out‐of‐hospital cardiac arrest, when conventional cardiopulmonary resuscitation (CPR) alone does not achieve return of spontaneous circulation, extracorporeal CPR is attempted to restore perfusion and improve outcomes. Considering the contrasting findings of recent studies, we conducted a meta‐analysis of randomized controlled trials to ascertain the effect of extracorporeal CPR on survival and neurological outcome. Methods: Pubmed via MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched up to February 3, 2023, for randomized controlled trials comparing extracorporeal CPR versus conventional CPR in adults with refractory out‐of‐hospital cardiac arrest. Survival with a favorable neurological outcome at the longest follow‐up available was the primary outcome. Results: Among four randomized controlled trials included, extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome at the longest follow‐up available for all rhythms (59/220 [27%] vs. 39/213 [18%]; OR = 1.72; 95% CI, 1.09–2.70; p = 0.02; I2 = 26%; number needed to treat of 9), for initial shockable rhythms only (55/164 [34%] vs. 38/165 [23%]; OR = 1.90; 95% CI, 1.16–3.13; p = 0.01; I2 = 23%; number needed to treat of 7), and at hospital discharge or 30 days (55/220 [25%] vs. 34/212 [16%]; OR = 1.82; 95% CI, 1.13–2.92; p = 0.01; I2 = 0.0%). Overall survival at the longest follow‐up available was similar (61/220 [25%] vs. 34/212 [16%]; OR = 1.82; 95% CI, 1.13–2.92; p = 0.59; I2 = 58%). Conclusions: Extracorporeal CPR compared with conventional CPR increased survival with favorable neurological outcome in adults with refractory out‐of‐hospital cardiac arrest, especially when the initial rhythm was shockable. Review Registration: PROSPERO CRD42023396482. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to assess the interdependence of extracorporeal blood flow (Qec) and gas flow (GF) in predicting CO2 removal and reduction of minute mechanical ventilation under extracorporeal respiratory support. Methods: All patients who benefited from V‐V ECMO and high‐flow ECCO2R in our intensive care unit over a period of 18 months were included. CO2 removal was calculated from inlet/outlet blood port gases during the first 7 days of oxygenator use. The relationship between the Qec × GF product (named decarboxylation index and expressed in L2/min2) and CO2 removal or expired minute mechanical ventilation reduction (ECMV ratio) was studied using linear regression models. Results: Eighteen patients were analyzed, corresponding to 24 oxygenators and 261 datasets. CO2 removal was 393 ml/min (IQR, 310–526) for 1.8 m2 oxygenators and 179 ml/min (IQR, 165–235) for 1.3 m2 oxygenators. The decarboxylation index was associated linearly with CO2 removal (R2 = 0.62 and R2 = 0.77 for the two oxygenators, respectively) and ECMV ratio (R2 = 0.72 and R2 = 0.62, respectively). The 20L2/min2 value (considering Qec = 2 L/min and GF = 10 L/min) was associated with an ECMV ratio between 61% and 29% for 1.8 m2 oxygenators, and between 62% and 38% for 1.3 m2 oxygenators. Conclusion: The decarboxylation index is a simple parameter to predict CO2 removal and ECMV ratio under extracorporeal respiratory support. [ABSTRACT FROM AUTHOR]

Background: The outcome after veno‐venous extracorporeal membrane oxygenation in elderly patients is supposed to be unsatisfactory. Our primary aim was to determine the influence of advanced age on short‐ and long‐term outcomes; the secondary aim was to analyze risk factors for impaired outcomes. Methods: Between January 2006 and June 2020, 755 patients received V‐V ECMO support at our department. Patients were grouped according to age (18–49.9, 50–59.9, 60–69.9, ≥70 years old), and then retrospectively analyzed for short‐ and long‐term outcomes. Risk factors for in‐hospital mortality and death during follow‐up were assessed using multivariate regression analysis. Results: Duration of V‐V ECMO support was comparable between all groups median (8–10 days, p = 0.256). Likewise, the weaning rate was comparable in all age groups 68.2%–76.5%; (p = 0.354), but in‐hospital mortality was significantly climbing with increasing age (<50 years 30.1%/n = 91 vs. 50–59.9 years 37.1%/n = 73, vs. 60–69.9 years 45.6%/n = 78 vs. ≥70 years 51.8%/n = 44; p < 0.001). Older age groups also showed significantly reduced cerebral performance category scores. The multivariate logistic analysis yielded age, acute and chronic hemodialysis, bilirubin on day 1 of support, malignancy, and primary lung disease as relevant risk factors for in‐hospital mortality. Age, coronary artery disease, presence of another primary lung disease, malignancy, and immunosuppression were risk factors for death during follow‐up. Conclusion: In V‐V ECMO patients, advanced age is associated with more comorbidity, impaired short‐ and long‐term outcome, and worse neurological outcome. [ABSTRACT FROM AUTHOR]

Background: Veno‐venous extracorporeal life support (V‐V ECLS or V‐V ECMO) has been adopted as a rescue support in severe cases of COVID‐19 ARDS. Initial reports on the use of V‐V ECLS in COVID‐19 patients reported very high mortality rates (57%–94%), but subsequent studies showed much lower rates (30%–40%). The aim of this study is to analyze demographic features, clinical course and outcomes of COVID‐19 treated with V‐V ECLS during the Italian 'third wave', in which the alpha variant was prevalent in the country. Methods: Single‐center, retrospective observational study conducted at the ECLS referral center of a teaching hospital in Italy from January 1st, 2021 and October 31st, 2021. Results: Between January and October 2021, 18 consecutive adult patients who underwent V‐V ECLS for severe ARDS due to COVID‐19 were enrolled. Thirteen patients (72.2%) were male, and their median age was 50 years; the median P/F ratio before V‐V ECLS initiation was 43 mm Hg (IQR, 40; 56), and the median RESP score was 0.5 (IQR, −2.25; 1.0). The mortality rate at 90 days was 55.6, compared to 55.7% in non‐COVID patients in our center (p > 0.05); the median duration of ECLS was 29 days (IQR, 11; 32), compared to 10 days (IQR, 8; 15), in non‐COVID patients (p = 0.004). Incidence of complications was high. Conclusions: In patients with COVID‐19 ARDS receiving V‐V ECLS, unadjusted mortality was similar to pre‐pandemic V‐V ECLS cases, while the duration of ECLS was almost three times longer and with frequent complications. This could be partly explained by the selection of very sick patients at the baseline that evolved to multiorgan failure during the course of ECLS. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) became an accepted therapy for the treatment of severe acute respiratory distress syndrome and chronic obstructive pulmonary disease. However, ECMO systems are still prone to thrombus formation and decrease of gas exchange over time. Therefore, it is necessary to conduct qualified studies to identify parameters for optimization of ECMO systems, and especially the oxygenator. However, commercially marketed oxygenators are not always appropriate and available for certain research use cases. Therefore, we aimed to design an oxygenator, which is suitable for various test conditions such as blood tests, numerical simulation, and membrane studies, and can be modified in membrane area size and manufactured in laboratory. Methods: Main design criteria are a homogeneous blood flow without stagnation zones, low pressure drop, manufacturability in the lab, size variability with one set of housing parts and cost‐efficiency. Our newly designed oxygenator was tested comparatively regarding blood cell damage, gas transfer performance and pressure drop to prove the validity of the design in accordance with a commercial device. Results: No statistically significant difference between the tested oxygenators was detected and our new oxygenator demonstrated sufficient hemocompatibility. Furthermore, our variable oxygenator has proven that it can be easily manufactured in the laboratory, allows to use various membrane fiber configurations and can be reopened easily and non‐destructively for analysis after use, and the original geometry is available for numerical simulations. Conclusion: Therefore, we consider this newly developed device as a valuable tool for basic experimental and numerical research on the optimization of oxygenators. [ABSTRACT FROM AUTHOR]

Background: Processes that activate the immune system during lung transplantation can lead to primary graft dysfunction (PGD) or allograft rejection. Methods: We analyzed cytokine expression profiles after reperfusion and allograft outcomes in a cohort of patients (n = 59) who underwent lung transplantation off‐pump (n = 26), with cardiopulmonary bypass (CPB; n = 18), or with extracorporeal membrane oxygenation (ECMO; n = 15). Peripheral blood was collected from patients at baseline and at 6 and 72 h after reperfusion. To adjust for clinical differences between groups, we utilized a linear mixed model with overlap weighting. Results: PGD3 was present at 48 or 72 h after reperfusion in 7.7% (2/26) of off‐pump cases, 20.0% (3/15) of ECMO cases, and 38.9% (7/18) of CPB cases (p = 0.04). The ECMO and CPB groups had greater reperfusion‐induced increases in MIP‐1B, IL‐6, IL‐8, IL‐9, IL1‐ra, TNF‐alpha, RANTES, eotaxin, IP‐10, and MCP‐1 levels than the off‐pump group. Cytokine expression profiles after reperfusion were not significantly different between ECMO and CPB groups. Conclusion: Our data suggest that, compared with an off‐pump approach, the intraoperative use of ECMO or CPB during lung transplantation is associated with greater reperfusion‐induced cytokine release and graft injury. [ABSTRACT FROM AUTHOR]

Background: ECMO support is associated with the development of a systemic hyper‐inflammatory response, which may become quite significant and extreme in some cases. We hypothesize that Cytosorb or Jafron therapy may benefit patients on V‐A ECMO in terms of levels of inflammatory markers such as IL‐6, complications, and overall outcomes. Methods: We conducted a retrospective study of prospectively collected data in a single tertiary care center between January 2021 and April 2022. At the time of the analysis of this article, 20 patients on V‐A ECMO had cytokine adsorption while on ECMO support: Cytosorb group (n = 10), Jafron group (n = 10). In 10 ECMO‐supported patients cytokine adsorption was not used, this group served as a control group, which may be quite significant in some cases. Evaluation of the level of inflammatory markers (IL‐1, 6, 8; CRP, Leukocyte, Lactate, PCT, NT‐proBNP, TNF‐α) was performed. Results: There was statistically significant longer CPB time, aortic cross‐clamp time and ICU stay in cytokine adsorption groups than in the control group, but there were no differences between subgroups with different types of haemoadsorption used. Moreover, in the control group mortality rate was higher than in the cytokine adsorption groups (60% vs. 20%, p = 0.02). All patients had an elevation of inflammatory markers in the perioperative and immediate postoperative periods. After 72 h of intensive care, blood inflammation markers had a tendency to decline. Conclusion: At the time of writing, hemadsorption in patients requiring V‐A ECMO support represents a good therapeutic effect. This effect is permanent for the whole period of extracorporeal cytokine hemadsorption application for both CytoSorb and Jafron HA330 devices. [ABSTRACT FROM AUTHOR]

Background: Use of veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) in elderly patients is controversial because of presumed poor outcome. Our primary aim was to determine the influence of advanced age on short‐ and long‐term outcome; the secondary aim was to analyze risk factors for impaired outcome. Methods: Between January 2006 and June 2020, 645 patients underwent VA‐ECMO implantation in our department. The patients were categorized into four groups:<50, 50–59.9, 60–69.9 and ≥70 years old. Data were retrospectively analyzed for short‐ and long‐term outcome. Risk factors for in‐hospital mortality and mortality during follow‐up were assessed using multivariate regression analysis. Results: VA‐ECMO support duration was comparable in all age groups (median 3 days). Weaning rates were 60.8%/n = 104 (<50 years), 51.4%/n = 90 (50–59.9 years), 58.8%/n = 107 (60–69.9), and 67.5%/n = 79 (≥70, p = 0.048). Hospital mortality was highest in the patients aged 50–59.9 years (68%/n = 119), but not in the elderly patients (60–69.9, ≥70:62.1%/n = 113, 58,1%/n = 68). At discharge, the cerebral performance category scores were superior in the patients <50 years. Multivariate logistic regression analysis revealed chronic kidney failure requiring hemodialysis, duration of cardiopulmonary resuscitation, and elevated blood lactate levels before VA‐ECMO, but not age as predictors of in‐hospital mortality. Cox's regression disclosed age as relevant risk factor for death during follow‐up. The patients' physical ability was comparable in all age groups. Conclusion: VA‐ECMO support should not be declined in patients only because of advanced age. Mortality and neurological status at hospital discharge and during follow‐up were comparable in all age groups. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) has salvaged many people's life during global pandemics. However, ECMO is associated with a high incidence of hemostatic complications. This study aims to explore the effects of the ECMO system on the coagulation system in the healthy ovine ECMO model. Methods: Ten healthy male sheep were included. Five received the veno‐arterial ECMO and five received the veno‐venous ECMO. Heparin was infused for systemic anticoagulation and was adjusted according to the activated clotting time. Blood routine tests, coagulation factors, anticoagulation proteins, and fibrinolysis markers were tested at the baseline and every 24 h. After weaning, the pump heads were dissected to explore thrombosis. Results: Platelets decreased in the first 72 h and returned to the baseline at the 120th hour. The neutrophils increased in the first 24 h and returned to the baseline at the 48th hour. Factors II, VII, and X decreased in the first 24 h and gradually increased, while factors VIII, IX, XI, and XII decreased in the first 24 h and remained at a low level. The baseline antithrombin was 73.2 ± 14.4% and reduced to 42.6 ± 9.9% at the 168th hour. Pathology showed seven sheep developed thrombus, but no clinically relevant bleeding or thrombosis events occurred. Conclusions: The study explored hemostatic alterations during ECMO in healthy animal models, which eliminated the confounding under critically ill conditions. The study may provide insights into ECMO hemostatic disorders and aid the design of optimal therapeutic strategies. [ABSTRACT FROM AUTHOR]

Background: Veno‐arterial extracorporeal life support (V‐A ECLS) has become a cornerstone in the management of critical cardiogenic shock, but it can also precipitate organ injury, e.g., acute kidney injury (AKI). Available studies highlight the effect of non‐cardiac organ injury on patient outcomes. Only very little is known about the impact of non‐cardiac organ recovery on patient survival. AKI occurs frequently during cardiogenic shock and carries a poor prognosis. We have developed descriptive models to hypothesize on the role of AKI severity versus that of recovery of renal function for patient survival. Methods: Retrospective, observational study including 175 patients who were successfully decannulated from V‐A ECLS. We assessed AKI severity using the "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria. We defined recovered or preserved renal function (RPRF) prior to decannulation from V‐A ECLS as 0 (AKI with no improvement) or 1 (no AKI or AKI with improvement). We classified patient outcomes as alive or dead at hospital discharge. Results: 78% (n = 138) of all patients survived hospital discharge of which 38% (n = 67) never developed AKI. After adjusting for shock severity and non‐renal organ injury, RPRF emerged as an independent predictor of survival in both the overall cohort [OR (95% CI) – 4.11 (1.72–9.79)] and the AKI‐only sub‐cohort [OR (95% CI) – 5.18 (1.8–14.92)]. Neither maximum KDIGO stage nor KDIGO stage at the end of V‐A ECLS was independently associated with survival. Conclusions: Our model identifies RPRF, but not AKI severity, as an independent predictor of hospital survival in patients undergoing V‐A ECLS for cardiogenic shock. We hypothesize that recovered or preserved non‐cardiac organ function during V‐A ECLS is crucial for patient survival. [ABSTRACT FROM AUTHOR]

Acute right ventricular (RV) failure following massive pulmonary embolism (PE) can have significant hemodynamic consequences and is the mode of death. Temporary mechanical circulatory support can provide tissue perfusion required while thrombectomy or lysis‐aimed therapies act to relieve the thrombotic obstruction. Veno‐arterial extracorporeal membrane oxygenation (V‐A ECMO) has conventionally been the first line MCS. A more selective approach to RV support has been advocated in the form of an extracorporeal right ventricular assist device (RVAD) as it mitigates some of the shortcomings of V‐A ECMO. We present the first case series of four patients who received fully percutaneous RVAD, with an integrated oxygenator forming an Oxy‐RVAD, for selective right heart support following massive PE, including the application of single‐access dual‐lumen right atrium to pulmonary artery cannula. All patients achieved RV recovery and were successfully weaned from oxy‐RVAD support within 5–10 days demonstrating the feasibility of selective percutaneous right heart support in managing these challenging patients. [ABSTRACT FROM AUTHOR]

Background: The impact of etiologies of acute fulminant myocarditis (AFM), which requires extracorporeal membrane oxygenation (ECMO), on clinical outcomes remains unknown. This study aimed to investigate the risk factors for ECMO weaning and mortality among patients with AFM due to viral etiologies in a tertiary referral medical center. Methods: We included 33 adults with AFM who received ECMO and were admitted between January 2002 and January 2021. General demographics, laboratory data, echocardiography findings, and long‐term outcomes were analyzed for confirmed viral etiology and unconfirmed etiology groups. Results: The overall hospital survival rate was 54.5%. The age, sex, severity of the hemodynamic condition, and cardiac rhythm were similar between the two groups. Multivariate Cox regression analysis revealed that a confirmed viral etiology (HR 4.201, 95% CI 1.061–16.666), peri‐ECMO renal replacement therapy (RRT) (HR 9.804, 1.140–83.333) and a high positive end‐expiratory pressure (PEEP) in the ventilator settings at 24 h after ECMO (HR 1.479, 1.020–2.143) were significant prognostic factors for in‐hospital mortality. Peri‐ECMO RRT was also a significant negative prognostic factor for successful ECMO weaning (OR 0.061, 0.006–0.600) in the multivariate logistic model. Conclusions: Among AFM patients receiving ECMO support, RRT use was associated with a decreased chance of survival to ECMO weaning. Multiple organ dysfunction and a high PEEP were also predictive of a lower chance of hospital survival. Those with a confirmed diagnosis of viral myocarditis may require more medical attention due to the higher risk of hospital mortality than those without a definite diagnosis. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation is a life‐saving therapy used in case of acute respiratory/circulatory failure. Exposure of blood to non‐physiological surfaces and high shear stresses is related to hemolytic damage and platelet activation. A detailed knowledge of the fluid dynamics of the components under different scenarios is thus paramount to assess the thrombogenicity of the circuit. Methods: An investigation of the flow structures developing in a conventional lighthouse tip (single‐staged) drainage cannula was performed with cross‐validated computational fluid dynamics and particle image velocimetry. The aim was to quantify the variation in drainage performance and stress levels induced by different fluid models, hematocrit and vessel‐to‐cannula flow rate ratios. Results: The results showed that the 90° bends of the flow through the side holes created a recirculation zone inside the cannula which increased residence time. Flow structures resembling a jet in a crossflow were also observed. The use of different hematocrits did not significantly affect drainage performances. The most proximal set of holes drained the largest fraction of fluid. However, different flow rate ratios altered the flow rate drained through the tip. The use of 2D data led to a 50% underestimation of shear rate levels. In the drainage zone the non‐Newtonian behavior of blood was less relevant. Conclusions: The most proximal holes drained the largest amount of fluid. The flow features and distribution of flow rates among the holes showed little dependence on the hematocrit. The non‐Newtonian behavior of blood had a small influence on the dynamics of the flow. [ABSTRACT FROM AUTHOR]

Background: Pulmonary artery (PA) cannulation is an effective extracorporeal life support (ECLS) management for left ventricular (LV) decompression or right ventricular (RV) support. This case series explores the results of PA cannulation during ECLS for acute cardiac failure. Methods: Patients receiving percutaneous PA cannulation between January 2017 and December 2020 in a single institution were retrospectively reviewed. Patients receiving PA cannulation by a surgical cutdown method were excluded. Based on the hemodynamic needs of the patients, percutaneous PA cannulation was applied with ECLS for LV unloading and/or RV support. The primary endpoint was the successful weaning from circulatory support. The secondary endpoints included 30‐day or in‐hospital mortality, significant periprocedural complications, and successful hospital discharge without major complications. Results: Fifteen patients (13 men, age range 11.2–70.8 years) presented acute heart failure and were initially managed by conventional ECLS mode. Percutaneous PA cannulation was performed for LV unloading in 13 patients (86.67%) and isolated RV circulatory support in two patients (13.33%). Weaning from circulatory support was achieved in 11 patients (73.33%). No significant periprocedural complication, including bleeding, infection, or vascular event requiring surgical exploration, was reported. The 30‐day or in‐hospital mortality rate was 33.33%. Eight cases (53.33%) were successfully discharged without major complications, including permanent stroke or the need for long‐term hemodialysis. Conclusions: PA cannulation, especially percutaneously performed, was effective and safe for LV unloading and/or RV support during ECLS. Further investigation is required to confirm the efficacy and safety of our approach and management in a larger patient population. [ABSTRACT FROM AUTHOR]