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Background. The 2018 Organ Procurement and Transplantation Network (OPTN) heart allocation policy change prioritizes patients bridged to transplant with mechanical circulatory support (MCS) devices, including extracorporeal membrane oxygenation (ECMO). As a result, the use of ECMO has significantly increased. Methods. We reviewed the OPTN database for adult patients undergoing heart transplant after bridge with ECMO between January 1st 2000 and October 18th 2018. We excluded patients with ≥180 days of ECMO duration, prior transplants, and those using additional MCS devices. Survival and morbidity outcomes of patients with ≥7 days of pre-transplant ECMO were compared to those of patients with <7 days. Results. Of 362 eligible transplant recipients, 163 (45%) utilized <7 days of pre-transplant ECMO and 199 (55%) utilized ≥7 days. Those with ≥7 days were younger (median age: 43 [28–54] vs. 50 [36–57] years, p = 0.006) and more likely to have temporary waitlist inactivity (18% vs. 7%, p = 0.003) with significantly longer duration of ECMO use (median: 14 [9–24] vs. 4 [2–5] days, p < 0.001). Patients with ≥7 days of ECMO had comparable survival to those with <7 days at one year (81.1% vs. 79.4%, p = 0.64) and five years (61.1% vs. 49.3%, p = 0.27). After adjustment for clinically relevant variables, duration of ECMO ≥7 days did not increase mortality at five years (HR = 0.90, p = 0.59). Conclusions. Longer duration of ECMO (≥7 days vs. <7 days) among patients successfully bridged to transplant is not associated with increased mortality or selected adverse outcome, including graft failure or rejection, at up to five years. [ABSTRACT FROM AUTHOR]

Background. Pulmonary hypertension is a well-known risk factor for hemodynamic instability after heart transplantation. However, it remains unclear whether a mild elevation of pulmonary artery systolic pressure (PASP) is associated with higher risks of graft dysfunction and resultant extracorporeal membrane oxygenation (ECMO) support. Methods. From 2016 to 2021, 102 adult recipients undergoing orthotopic heart transplantation at our institution were investigated (mean age, 48.5 ± 13.2 years; 22.5% female). This study cohort was stratified into 3 groups based on the PASP measured by right heart catheterization before surgery: >50 mmHg, 35–50 mmHg, and <35 mmHg. The primary end point was ECMO support after procedure. Results. ECMO was implemented in 24 (23.5%) patients due to difficult weaning from cardiopulmonary bypass or cardiac low output in the intensive care unit, which was likely to be associated with higher mortality (P = 0.053). Age, gender, comorbidities, preoperative medications, and graft ischemia time were comparable across the 3 groups. The use of ECMO was significantly more common in patients with baseline PASP >50 mmHg (11/36, 30.6%) and 35–50 mmHg (12/38, 31.6%), while only 1 (3.6%) patient with baseline PASP <35 mmHg required ECMO support after transplant (P = 0.007). Multivariate logistic models demonstrated that PASP (odds ratio = 2.34; P = 0.028) and cardiopulmonary bypass time (odds ratio = 1.01; P < 0.001) were independent risk factors for postoperative ECMO. Conclusions. A mild elevation of pretransplant PASP (e.g., 35–50 mmHg) is related to low cardiac output and subsequent ECMO after heart transplantation, for which prompt administration of vasodilators before transplant may be protective. [ABSTRACT FROM AUTHOR]

Background: Four‐factor prothrombin complex (PCC4), a concentrate of factors II, VII, IX, and X and proteins C and S, has been used selectively for reversal of oral anticoagulation before surgery. There is data to support PCC4 as opposed to supplemental fresh frozen plasma (FFP) to manage postoperative bleeding following cardiac surgery. The preemptive, intraoperative use of PCC4 in cardiothoracic surgery has not been studied though it may prevent postoperative bleeding, the need for blood transfusion and the risk of transfusion‐related acute lung injury, volume overload, and right ventricular (RV) heart failure. The purpose of this study is to evaluate the intraoperative administration of PCC4 to decrease bleeding and lower the rate of blood transfusion. Methods: A single institution retrospective chart review was conducted from May 2020 to November 2021 of patients who received PCC4 intraoperatively during cardiothoracic surgery of high‐risk variety. Patients were evaluated for the type of surgery, demographics, baseline anticoagulation, PCC4 dose, type and quantity of blood transfusion within 72 hours (h) postoperatively, chest tube output, the incidence of RV failure, hypersensitivity reactions, acute kidney injury (AKI), thrombosis, acute lung injury, and mortality within 45 days of the operative dose of PCC4. Results: Thirty‐five patients received PCC4 at a mean dose of 2920 units (U). Sixty‐five percent of cases were left ventricular assist devices (LVADs) or heart transplants. The protocol is to use PCC4 30 units (U)/kg immediately after the completion of protamine administration. Inclusion criteria are cardiothoracic surgery with increased risk of postoperative right heart failure commonly secondary to blood product transfusion, or cardiothoracic surgery associated with increased risk of bleeding, including heart transplant, LVAD implant, aortic dissection, and redo sternotomy (e.g., coronary artery bypass). Total chest tube output was recorded as a mean of 757 ml for 24 h after surgery (32 ml/h). Overall median event rates of FFP and red blood cell (RBC) transfusions were 0 (interquartile range [IQR]: 0–3 U) and 4 (IQR: 2–5 U). Overall, 43% and 89% of cases received FFP and RBC, respectively. There was one occurrence of RV failure, one occurrence of AKI requiring renal replacement therapy, one occurrence of venoarterial extracorporeal membrane oxygenation, one occurrence of venous thromboembolism related to a central venous access line, and one death unrelated to surgery or PCC4 that was attributed to advanced heart failure not amenable to advanced therapies. Conclusion: Overall patients received a low rate of blood transfusion, had minimal chest tube output, and there was a small incidence of right heart failure. Patients did not have an increased risk of adverse effects such as AKI or venous thromboembolism. A randomized controlled clinical trial comparing the observed dose and timing of PCC4 versus routine postoperative bleeding management with blood product transfusion is recommended. [ABSTRACT FROM AUTHOR]

Background: Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) is increasingly used as a bridge to cardiac transplantation. As the 2018 United Network for Organ Sharing (UNOS) heart allocation policy change elevated waitlist status for patients receiving mechanical circulatory support (MCS), we aimed to determine if a center's annual heart transplant volume was associated with ECMO‐support duration and posttransplant outcomes. Methods: Adults heart transplant candidates between January 1, 2011, and December 31, 2021, were isolated in the UNOS database. VA‐ECMO use was identified at the time of listing for transplant. Average annual transplant volume was calculated by the center, with stratification as high (≥20 cardiac transplants, high volume center [HVC]) or low (<20 cardiac transplants, low volume center [LVC]) volume centers. Results are reported as mean (interquartile range) or n (%). Results: In total, 543 patients at HVCs and 275 at LVCs were listed for transplant supported with VA‐ECMO. Those listed at HVCs were more likely to be supported by intra‐aortic balloon pump (103 [19%] vs. 32 [11.6%], p =.008) and inotropes (267 [49.2%] vs. 106 [38.5%], p =.004) at time of listing. Patients at HVCs received ECMO support for 6 [4–9] days, compared to 8 [4–15] days at low‐volume centers (p =.030), and but were cannulated a similar time before listing (2 [1–5] vs. 3 [1–7] days, p =.517). There were no differences in rates of transplant (p =.2126), waitlist mortality (p =.8645), delisting due to clinical deterioration (p =.8419), or recovery (p =.1773) between groups. Among transplanted patients, there were no differences in support duration (6 [4–8] vs. 6 [4–10], p =.187), or time from registration to transplant (5 [2–20] vs. 7 [3–22] days, p =.560). Posttransplant survival did not vary (p =.293). Conclusions: LVCs can successfully bridge patients to transplant with VA‐ECMO and achieve comparable outcomes to HVCs. [ABSTRACT FROM AUTHOR]

Background and Aim: The mortality rate of patients with post‐myocardial infarction (MI) ventricular septal defects (VSDs) is high, and the benefit of surgery is unclear. We aimed to investigate the management and outcomes of post‐MI VSD over a 10‐year period in a large cohort. Methods: Data of patients with post‐MI VSD admitted in three French university hospitals from 2008 to 2019 were examined. The characteristics of those who underwent surgery were compared with those who received medical treatment. Mortality risk factors, survival curves, and outcomes at 30 days and 1 year after treatment were determined. Results: Of the 92 patients whose data were examined, 50 underwent surgery and 42 received exclusive medical treatment. All patients were critically ill. Overall, 76.1% of patients received inotropic support, and 63% received mechanical ventilation. Circulatory assistance, mainly via intra‐aortic balloon pump and extra‐corporeal membrane oxygenation, was provided to 46.7% patients, with 14.1% requiring a second assistance. The median time to surgery was 4 days. At 1 year, mortality was 46% in those who underwent surgery and 83.3% in those treated medically (p <.001). Survival curves at 1 and 3 months showed major differences, and the survival rate showed little change 30 days after treatment. Cardiogenic shock and cardiac arrest emerged as risk factors for mortality. Conclusions: In our retrospective, multicenter study, the mortality resulting from post‐MI VSD did not seem to improve over the last decade. Although surgery carried considerable risks, it improved survival. [ABSTRACT FROM AUTHOR]

Background: Acute respiratory and circulatory collapse might occasionally happen after pulmonary endarterectomy (PEA). We aimed to investigate the utilization of extracorporeal membrane oxygenation (ECMO) after PEA and potential risk factors. Methods: Demographic characteristics, clinical and surgical data were collected for all patients who underwent PEA from December 2016 to June 2022. All factors were compared between patients in the ECMO group and those in the other group. The most characteristic risk factors were obtained by least absolute shrinkage and selection operator regression and support vector machine machine learning, and receiver operating characteristics (ROC) Curve analysis was performed to verify the diagnostic value of the obtained risk factors. Results: A total of 117 patients underwent PEA, and 8 (6.8%) of them received ECMO treatment intraoperatively or postoperatively. There were significant differences between the two groups in terms of cardiac function, pulmonary vascular resistance (PVR), preoperative inflammation and cardiopulmonary bypass time. The PVR and neutrophil‐to‐lymphocyte ratio (N/L ratio) were the most characteristic risk factors with an area under the ROC curve of 0.847 (95% confidence interval [CI] = 0.7517–0.9420, p =.005) and 0.896 (95% CI = 0.803–0.989, p =.001), respectively. The ECMO group had higher PVR (1549.4 ± 600.7 vs. 952.9 ± 466.9 dyn.s.cm−5, p =.004) and N/L ratio (6.3 ± 5.6 vs. 2.4 ± 1.7, p =.001). Conclusions: PVR and N/L ratio can correctly predict who is likely to receive ECMO treatment after PEA. Therefore, addressing the preoperative inflammatory status might be beneficial but further research is needed. [ABSTRACT FROM AUTHOR]

Background: Although all congenital heart defects (CHD) present unique challenges, univentricular CHD are especially challenging given the difficulty of passively perfusing pulmonary blood flow. Three surgical procedures are required within the first years of life, with the final completing a Fontan circulation in which the inferior vena cava is connected to the pulmonary artery and previously connected superior vena cava. This allows passive venous return to the pulmonary circulation then flow into the single ventricle for systemic circulation. Methods: Although a Fontan provides successful palliation for two to three decades, many complications can arise as pulmonary resistance must remain low to allow adequate forward flow. Eventually, the failing Fontan circulation requires temporary support as the patient awaits a heart transplant. We reviewed PubMed, Google Scholar, and U. Kentucky library for different techniques evaluated to support a failing Fontan circulation. Results: Multiple technologies have been developed as a bridge to transplant to decrease morbidity. Innovative types of extracorporeal membrane oxygenation, ventricular assist devices, and total artificial hearts have been attempted in laboratory settings as well as in Fontan patients with varying degrees of success. This article emphasizes the strengths and weaknesses of each technology in the context of Fontan physiology. Conclusion: The end game for these patients remains a heart transplant. Without easy access to donors, each of the options discussed is a potential bridge to limit morbidity and mortality until a suitable donor heart becomes available. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID‐19) pneumonia can be associated with refractory respiratory failure requiring extracorporeal membrane oxygenation(ECMO). Although ECMO has helped many COVID patients, optimal management strategies for these patients remain unknown. Methods: We conducted a retrospective review of all COVID patients requiring ECMO at our hospital. Six months into the pandemic, we changed our management strategy to focus on early mobilization. The early mobilization effort included tracheostomy within 48 h of cannulation, decreasing sedation, and an aggressive physical and occupational therapy program progressing toward early ambulation while on ECMO. The primary outcome measured was survival to discharge. The primary stratification was based on the mobilization strategy. Results: From 2020 to 2021, 47 COVID patients have been supported with ECMO at our institution. Five are still in the hospital on ECMO. 39 (83%) were supported with venovenous ECMO while 8 (17%) were supported with venoarterial or a right ventricular assist device type configuration. All 47 (100%) were cannulated at bedside with transesophageal echocardiographic guidance. The average age was 47 ± 9 years; 36(77%) were male; and 20 (43%) were Hispanic. The median duration of support was 22 (11–44) days. Excluding those who remain in the hospital and on support, overall survival to discharge was 24/42 (57%). When stratified by mobilization strategy, early tracheostomy and mobilization were associated with significantly improved survival (74% [17/23] vs. 37% [7/19], p =.02). There were no changes in patient acuity or duration of support throughout the study period. Conclusion: In conclusion, early tracheostomy, decreased sedation, and aggressive mobilization of COVID‐19 ECMO patients is associated with improved survival. [ABSTRACT FROM AUTHOR]

Background: Although several studies have characterized the risk of coinfection in COVID pneumonia, the risk of the bloodstream and respiratory coinfection in patients with COVID‐19 pneumonia on extracorporeal membrane oxygenation (ECMO) supports severe acute respiratory distress syndrome (ARDS) is poorly understood. Methods: This is a retrospective analysis of patients with COVID‐19 ARDS on ECMO at a single center between January 2020 and December 2021. Patient characteristics and clinical outcomes were compared. Results: Of 44 patients placed on ECMO support for COVID‐19 ARDS, 30 (68.2%) patients developed a coinfection, and 14 (31.8%) patients did not. Most patients underwent venovenous ECMO (98%; 43/44) cannulation in the right internal jugular vein (98%; 43/44). Patients with coinfection had a longer duration of ECMO (34 [interquartile range, IQR: 19.5, 65] vs. 15.5 [IQR 11, 27.3] days; p =.02), intensive care unit (ICU; 44 [IQR: 27,75.5] vs 31 [IQR 20–39.5] days; p =.03), and hospital (56.5 [IQR 27,75.5] vs 37.5 [IQR: 20.5–43.3]; p =.02) length of stay. When stratified by the presence of a coinfection, there was no difference in hospital mortality (37% vs. 29%; p =.46) or Kaplan–Meier survival (logrank p =.82). Time from ECMO to first positive blood and respiratory culture were 12 [IQR: 3, 28] and 10 [IQR: 1, 15] days, respectively. Freedom from any coinfection was 50 (95% confidence interval: 37.2–67.2)% at 15 days from ECMO initiation. Conclusions: There is a high rate of co‐infections in patients placed on ECMO for COVID‐19 ARDS. Although patients with coinfections had a longer duration of extracorporeal life support, and longer length of stays in the ICU and hospital, survival was not inferior. [ABSTRACT FROM AUTHOR]

Background: Over the past decade, several minimally invasive mechanical support devices have been introduced into clinical practice to support the right ventricle (RV). Percutaneous cannulas are easy to insert, minimally invasive, and treat acute RV failure rapidly. In December 2021, the Food and Drug Administration approved a new 31 French dual lumen single cannula for use as a right ventricular assist device.Aims: Descirbe the use of the new dual lumen percutaneous right ventricular assist device (RVAD) cannula.Material and Methods: Deployment of the RVAD can be done surgically or percutaneously. This cannula, manufactured by Spectrum, is dual staged. It has inflow ports positioned both in the right atrium (RA) as well as the RV for maximal drainage of the right heart. The distal end of the cannula which includes the outflow port is positioned in the pulmonary artery (PA).Results: Deployment of the Spectrum RVAD can be done percutaneously with transesophageal and flouroscopy guidence. Cannulation requires requisite wire skills in order to navigate into the main pulmonary artery. Utilization of this cannula can be done in acute RV failure secondary to ischemia, post cardiotomy shock, acute respiratory failure or other causes of isolated RV failure.Discussion: The dual stage drainage design optimizes venous drainage as well as limits suck-down events. Theoretically, direct RV decompression also decreases RV dilation and wall tension, and facilitates improved transmural pressure gradient to reduce RV strain.Conclusion: Here we describe the first-in-man successful use of the dual-stage RA and RV to PA Spectrum cannula in a patient with severe COVID acute respiratory distress syndrome and acute right ventricular failure, bridged to recovery. [ABSTRACT FROM AUTHOR]

Background and Aim of the Study: Acute cardiovascular failure remains a leading cause of death in severe poisonings. Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) has been increasingly used as a rescue therapeutic option for those cases refractory to optimal conventional treatment. We sought to evaluate the outcomes after VA‐ECMO used for drug intoxications in a single‐center experience. Methods: We performed an observational analysis of our prospective institutional database. The primary endpoint was survival to hospital discharge. Results: Between January 2007 and December 2020, 32 patients (mean age: 45.4 ± 15.8 years; 62.5% female) received VA‐ECMO for drug intoxication‐induced refractory cardiogenic shock (n = 25) or cardiac arrest (n = 7). Seven (21.8%) patients developed lower limb ischemia during VA‐ECMO support. Twenty‐six (81.2%) patients were successfully weaned after a mean VA‐ECMO support of 2.9 ± 1.3 days. One (3.1%) patient died after VA‐ECMO weaning for multiorgan failure and survival to hospital discharge was 78.1% (n = 25). In‐hospital survivors were discharged from hospital with a good neurological status. Survival to hospital discharge was not statistically different according to sex (male = 75.0% vs. female = 80.0%; p =.535), type of intoxication (single drug = 81.8% vs. multiple drugs = 76.1%; p =.544) and location of VA‐ECMO implantation (within our center = 75% vs. peripheral hospital using our Mobile Unit of Mechanical Circulatory Support = 100%; p =.352). Survival to hospital discharge was significantly lower in patients receiving VA‐ECMO during on‐going cardiopulmonary resuscitation (42.8% vs. 88.0%; p =.026). Conclusions: VA‐ECMO appears to be a feasible therapeutic option with a satisfactory survival rate and acceptable complications rate in poisonings complicated by refractory cardiogenic shock or cardiac arrest. [ABSTRACT FROM AUTHOR]

Death by neurologic criteria (DNC) requires coma, absent brainstem reflexes, and the inability to breathe independently during apnea testing (AT). For patients on extracorporeal membrane oxygenation (ECMO), this clinical determination is more challenging. Herein, we report the case of a patient with DNC on ECMO post cardiac surgery, highlighting various considerations to the process and modifications required for AT. [ABSTRACT FROM AUTHOR]

Background: Infectious complications have been shown to increase the morbidity of venous‐venous extracorporeal membrane oxygenation (VV‐ECMO) population, including the use of right ventricular assist devices. Aim: We aimed to evaluate our VV‐ECMO population for ECMO related bloodstream infections (E‐BSI) and characteristics that affect risk and overall outcomes. Methods: A retrospective chart review of adult patients (>18 years of age)supported with VV ECMO was conducted. Demographic data as well as antimicrobial use and presecence of bacteremia was collected. Results: We report a low infection rate of 2.7%. Conclusions: We postulate our low BSI rate may be due to our use of perioperative antimicrobials as well as a majority of our cannulations occurring in the operating room. We do not routinely utilize prophylactic antimicrobials on ECMO. Further investigation into trends, risks, and outcomes related to E‐BSI is needed. [ABSTRACT FROM AUTHOR]

Background: With increasing extracorporeal membrane oxygenation (ECMO) utilization over the last decade, clinicians have developed "hybrid" configurations to meet complex perfusion requirements. In the setting of differential hypoxemia, a veno‐arteriovenous (V‐AV) configuration provides oxygenated cardiac preload and hemodynamic support to satisfy physiologic demands. We aim to further characterize the patient population, indications, and outcomes associated with this hybrid configuration. Methods: We retrospectively reviewed all adult patients placed on V‐AV ECMO at our institution from June 2016 to December 2019. Through a review of the electronic medical records, data describing demographic features, comorbidities, and ECMO‐specific information were analyzed systematically. Results: 14 patients were placed on V‐AV ECMO during the study period. Our cohort was 79% male with a median age of 54 and BMI of 30.3. These patients had a median SOFA‐0 score of 15 and SAVE score of ‐12. Patients were treated with ECMO support for a median of 144.1 (IQR 98.5 – 183.1) hours, consisting of 0.2 (IQR 0 – 17.7) hours of VA and 92.4 (IQR 53.7 – 115.1) hours of V‐AV followed by 67.4 (IQR 20.3 – 96.6) hours of VV support. Of these 14 patients, 11 survived to decannulation (79%) and 9 survived to hospital discharge (64%). Conclusion: ECMO patients with recovering left ventricular function and persistent gas exchange abnormalities are at risk for developing differential hypoxemia. We describe an approach to utilizing V‐AV configuration when the likelihood of differential hypoxemia is extremely high, with a survival rate that compares favorably to Extracorporeal Life Support Organization statistics and published case series. [ABSTRACT FROM AUTHOR]

The mortality rate after the development of postinfarction ventricular septal defect remains high despite progress in pharmacologic therapy, invasive cardiology, and surgical techniques. We present a case series of six patients with preoperative venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgical repair. Venoarterial extracorporeal membrane oxygenation allows to hemodynamically stabilize the patient, and safely delay the surgery. Delayed surgery might facilitate successful repair by allowing friable tissue to organize, strengthen, and become well‐differentiated from surrounding healthy tissue; thus, definite repair can be performed safely. All patients were in cardiogenic shock and would otherwise require emergent cardiac surgery with associated risk. Three patients were discharged, with one hospital mortality of a patient who had a successful bridge to corrective surgery and died due to pulmonary artery rupture after a right ventricular assist device implantation. Two patients died before surgery while they were supported by venoarterial extracorporeal membrane oxygenation due to vascular complications. We discuss strategies how to optimize the management and function of the venoarterial extracorporeal membrane oxygenation to decrease the rate of adverse effects and optimize the outcomes of these patients. [ABSTRACT FROM AUTHOR]

Emerging data suggest an association between severe acute respiratory syndrome coronavirus 2 and the development of acute myocarditis, with children and older adults being most at risk. We describe the clinical course of a previously healthy 12‐year‐old female who rapidly deteriorated into cardiogenic shock and arrest due to coronavirus disease 2019 induced fulminant myocarditis, necessitating venous‐arterial extracorporeal membrane oxygenation as a bridge to full recovery. This case highlights the importance of early clinical recognition of myocardial involvement, and the benefits of taking a multidisciplinary approach in treating these patients. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) has been associated with acceptable short‐term survival in patients with refractory respiratory failure secondary to coronavirus disease 2019 (COVID‐19) pneumonia. Previous studies have demonstrated acceptable long‐term outcomes in patients supported with ECMO for respiratory failure of other etiologies. However, long‐term survival and functional outcomes in COVID ECMO patients remain unknown. Methods: We conducted a retrospective review of all COVID patients requiring ECMO at our hospital. The primary outcomes measured were survival to discharge and contemporary survival. Secondary outcomes included two simple functional assessments: the ongoing need for oxygen supplementation and the ability to return to work. Survival was calculated using the Kaplan–Meier method. Hazard ratios were calculated using Cox hazards regression models. Results: From 2020 to 2021, 48 COVID patients have been supported with ECMO at our hospital. Four patients remain on support and were excluded from further analysis. The average age was 47 ± 8 years, 34 (77%) were males, and the plurality (19, 43%) were Hispanic. Median duration of support was 23 (12–51) days. Median follow‐up was 106 (29–226) days. Survival to discharge was 59%. Kaplan–Meier 180‐day survival was 51%. Long‐term survival conditioned on survival to discharge was 89%. In evaluating functional outcomes, the overwhelming majority of patients no longer required oxygen supplementation (74%), and most had returned to work (52%). Conclusion: In conclusion, COVID ECMO patients have acceptable intermediate‐term survival with adequate functional recovery. [ABSTRACT FROM AUTHOR]

Objectives: Venovenous extracorporeal membrane oxygenation (VV‐ECMO) is increasingly being used in acutely deteriorating patients with end‐stage lung disease as a bridge to transplantation (BTT). It can allow critically ill recipients to remain eligible for lung transplants (LTx) while reducing pretransplant deconditioning. We analyzed early‐ and midterm postoperative outcomes of patients on VV‐ECMO as a BTT and the impact of preoperative VV‐ECMO on posttransplant survival outcomes. Methods: All consecutive LTx performed at our institution between January 2012 and December 2018 were analyzed. After matching, BTT patients were compared with nonbridged LTx recipients. Results: Out of 297 transplanted patients, 21 (7.1%) were placed on VV‐ECMO as a BTT. After matching, we observed similar 30‐day mortality between BTT and non‐BTT patients (4.6% vs. 6.6%, p =.083) despite a higher incidence of early postoperative complications (need for ECMO, delayed chest closure, and acute kidney injury). Furthermore, preoperative VV‐ECMO did not appear associated with 30‐day or 1‐year mortality in both frequentist and Bayesian analysis (odds ratio [OR]: 0.35, 95% confidence interval: 0.03–3.49, p =.369; OR: 0.27, 95% credible interval: 0.01–3.82, p = 84.7%, respectively). In sensitivity analysis, both subgroups were similar in respect to 30‐day (7.8% vs. 6.5%, p =.048) and 1‐year mortality (12.5% vs. 18%, p =.154). Conclusions: Patients with acute refractory respiratory failure while waiting for LTx represent a high‐risk cohort of patients. VV‐ECMO as a BTT is a reasonable strategy in adult patients with acceptable operative mortality and 1‐year survival comparable to non‐BTT patients. [ABSTRACT FROM AUTHOR]

Background: The optimal treatment of high‐risk pulmonary embolism (PE) with cardiac arrest is still controversial although various treatment approaches have been developed and improved. Here, we present a serie of patients with high‐risk PE showing hemodynamic collapse, who were successfully treated with extracorporeal membrane oxygenation (ECMO) as an adjunct to EKOS™ acoustic pulse thrombolysis (APT). Methods: From April 2016 to June 2020, 29 patients with high‐risk PE with cardiac arrest were retrospectively included. The mean age was 55.3 ± 9.2 years. A total of 12 (41.3%) patients were female. All patients had cardiac arrest, either as an initial presentation or in‐hospital after presentation. All patients exhibited acute symptoms, computed tomography evidence of large thrombus burden, and severe right ventricular dysfunction. Primary outcome was all‐cause 30‐day mortality. Results: Twenty‐two patients survived to hospital discharge, with a mean intensive care unit stay of 9.9 ± 1.6 days (range: 7–22 days) and mean length of hospital stay of 23.7 ± 8.5 days (range: 11–44 days). Six patients died from refractory shock. Ninety‐day mortality was 24.1% (7/29). The Mean ECMO duration was 3.5 ± 1.1 days and the mean RV/LV ratio decreased from 1.31 ± 0.17 to 0.92 ± 0.11 in patients who survived to discharge. The mean tissue plasminogen activator dose for survivor patients was 20.5 ± 1.6 mg. Conclusion: Patients with high‐risk pulmonary embolism who suffer a cardiac arrest have high morbidity and mortality. APT complemented by ECMO could be a successful treatment option for the patients who have high‐risk PE with circulatory collapse. [ABSTRACT FROM AUTHOR]

Background: Frailty influences the postoperative outcomes in patients undergoing left ventricular assist device (LVAD) implantation. Recently, erector spinae muscle (ESM) mass has been proposed as a parameter to assess frailty accurately. Thus, the purpose of the present study was to evaluate whether preoperative ESM mass is associated with short‐ and long‐term clinical outcomes in patients with LVAD. Methods: A total of 119 consecutive patients with LVAD were enrolled between January 2010 and October 2017 at a single heart center. The ESM area, ESM index, and Hounsfield units (HU) of the ESM were calculated by computed tomography for preoperative ESM mass evaluation. We then statistically evaluated the in‐hospital mortality, major adverse cardiovascular events (MACE), duration of hospital stay, and long‐term survival. Results: In a multivariate Cox regression analysis, ESM mass indicated no effect on all clinical outcomes. In addition, the ESM area presented a weak but significant negative linear correlation only with the duration of hospital stay (r = −0.21, p <.05). In contrast, the Model For End‐stage Liver Disease (MELD) score and preoperative venous‐arterial extracorporeal membrane oxygenation (va‐ECMO) were significant predictive factors for in‐hospital mortality (MELD score: p <.001, hazard ratio [HR] 1.1; preoperative va‐ECMO: p <.01, HR 2.72) and MACE (MELD score: p <.001, HR 1.07; preoperative va‐ECMO: p <.005, HR 2.62). Conclusion: Preoperative ESM mass might predict the length of hospital stay in patients undergoing LVAD implantation. In contrast, it had no effect on MACE, in‐hospital mortality, or long‐term survival in this study. [ABSTRACT FROM AUTHOR]

Background: Heart transplant (HT) from controlled donation after circulatory death (cDCD) is an emerging strategy that is rapidly expanding and may help increase the heart donor pool. Materials and Methods: The use of thoracoabdominal normothermic regional perfusion with extracorporeal membrane oxygenation device has allowed to perform HT after cDCD in our country. We present a successful case of heart transplantation using a graft from cDCD with 201 min cold ischemia time. Discussion and Conclusion: HT from cDCD could be a good alternative to brain dead donation. This experience suggests than nonlocal cardiac from cDCD could tolerate long periods of cold ischemia time and break the main barriers with this technique. [ABSTRACT FROM AUTHOR]

Understanding outcomes of emergency aortic dissection repair during COVID-19 pandemic: What lessons have we learnt? Keywords: acute aortic dissection; COVID-19; outcomes; Society of Thoracic Surgeons Database EN acute aortic dissection COVID-19 outcomes Society of Thoracic Surgeons Database 4552 4554 3 01/02/23 20221201 NES 221201 The COVID-19 pandemic caused a global strain on healthcare resources and infrastructure in more than 180 countries. Therefore, outcomes between COVID positive patients and COVID negative patients cannot be compared. [Extracted from the article]

Background: Currently, no absolute contraindications to the use of extracorporeal membrane oxygenation (ECMO) support exist. However, the presence of penetrating traumatic injuries is often considered a relative contraindication to ECMO support. In this study, we aim to assess whether penetrating traumatic injuries should be considered a contraindication to the use of ECMO support, and how to better select patients who may benefit from this therapy. Materials and Methods: In this paper, we present the findings of a retrospective review of all patients at a large, level 1 trauma center who received ECMO support following penetrating traumatic injuries. We describe the use of ECMO in these patients along with the complications associated with this therapy. Conclusion: In this study we show penetrating traumatic injuries should not be considered a contraindication to ECMO support, and how ECMO can be a useful treatment strategy in selected patients with these injuries. [ABSTRACT FROM AUTHOR]

Background: A 63-year-old male who presented with acute anterior wall myocardial infarction with ischemic ventricular septal defect (VSD) required veno-arterial extracorporeal membrane oxygenation support due to a profoundly reduced left ventricular function.Method and Resuls: The VSD was closed with a large bovine pericardial patches. Another Dacron patch was used to close the defect on the anterior wall. The inflow cannula of the left ventricular assist device (LVAD) was sewn to the Dacron patch to secure hemostasis and to maintain the cavity in the left ventricle. The Dacron patch beneath the inflow cuff was then incised, then the LVAD was connected.Conclusions: we described a case of concomitant insertion of durable LVAD and repair of ischemic VSD utilizing multiple patches. [ABSTRACT FROM AUTHOR]

Background: Heart transplantation from controlled donation after the circulatory determination of death (cDCDD) may be an option to increase the pool of grafts for transplantation. Materials and Methods: Initial experiences on cDCDD heart transplantation were based on the direct procurement of the heart followed by preservation with ex situ perfusion devices. Later, the use of thoracoabdominal normothermic regional perfusion (TA‐NRP) has emerged as an option to recover hearts. We present a case of a heart transplant using a graft from controlled donation after circulatory death. Cardiac preservation was performed by postmortem TA‐NRP followed by cold storage. Ex situ perfusion device was not used. Discussion and Conclusion: This is one of the first published cases of a controlled donation after circulatory death heart retrieved using only TA‐NRP and successfully transplanted. [ABSTRACT FROM AUTHOR]

Background: Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death. For patients who are hemodynamically unstable, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support has been shown to provide hemodynamic stability, and allow time for definitive treatment and recovery. Ultrasound-assisted catheter directed thrombolysis (USAT) has the potential to be a safe adjunct and expedite right ventricular (RV) recovery for patients requiring VA-ECMO for PE.Methods: A review of all VA-ECMO patients from January 2017 to September 2019 was performed. A total of 49 of these patients were cannulated due to a PE. USAT therapy was used as an adjunct in 6 (12%) of these patients. These 6 patients were given standardized USAT therapy with EKOs catheters at 1 mg/h of tissue plasminogen activator with an unfractionated heparin infusion for additional systemic anticoagulation. Outcomes, including in-hospital death, 90-day survival, RV recovery, and complications, were examined in the cohort of patients that received USAT as an adjunct to ECMO.Results: Median age was 54 years old. Five of the six patients presented with a massive PE and had a PE severity score of Class V. One patient presented with a submassive PE with a Bova score of 2, but was cannulated to VA-ECMO in the setting of worsening RV function. All patients demonstrated recovery of RV function, were free from in-hospital death, and were alive at 90-day follow-up.Conclusion: Ekosonic endovascular system therapy may be a safe and feasible adjunct for patients on VA-ECMO for PE, and allow for survival with RV recovery with minimal complications. [ABSTRACT FROM AUTHOR]

Objective: Implantation of donor hearts with prolonged ischemic times is associated with worse survival. We sought to identify risk factors that modulate the effects of prolonged preservation. Methods: Retrospective review of the United Network for Organ Sharing database (2000–2018) to identify transplants with >5 (n = 1526) or ≤5 h (n = 35,733) of donor heart preservation. In transplanted hearts preserved for >5 h, Cox‐proportional hazards identify modifiers for survival. Results: Compared to ≤5 h, transplanted patients with >5 h of preservation spent less time in status 1B (76 ± 160 vs. 85 ± 173 days, p =.027), more commonly had ischemic cardiomyopathy (42.3% vs. 38.3%, p =.002), and less commonly received a blood type O heart (45.4% vs. 50.8%, p <.001). Longer heart preservation time was associated with a higher incidence of postoperative stroke (4.5% vs. 2.5%, p <.001), and dialysis (16.4% vs. 10.6%, p <.001). Prolonged preservation was associated with a greater likelihood of death from primary graft dysfunction (2.8% vs. 1.5%, p <.001) but there was no difference in death from acute (2.0% vs. 1.7%, p =.402) or chronic rejection (2.0% vs. 1.9%, p =.618). In transplanted patients with >5 h of heart preservation, multivariable analysis identified greater mortality with ischemic cardiomyopathy etiology (hazard ratio [HR] = 1.36, p < 0.01), pre‐transplant dialysis (HR = 1.84, p <.01), pre‐transplant extracorporeal membrane oxygenation (ECMO, HR = 2.36, p =.09), and O blood type donor hearts (HR = 1.35, p <.01). Conclusion: Preservation time >5 h is associated with worse survival. This mortality risk is further amplified by preoperative dialysis and ECMO, ischemic cardiomyopathy etiology, and use of O blood type donor hearts. [ABSTRACT FROM AUTHOR]

Coronavirus disease 2019 (COVID‐19) causes the development of severe acute respiratory distress syndrome. Pregnant women may be at increased risk for the development of severe disease. We present the case of a pregnant patient who developed respiratory failure due to COVID‐19 and rapidly decompensated requiring intubation. Despite mechanical ventilation, the patient's respiratory status continued to worsen. At bedside, cardiothoracic surgeons, obstetricians, intensivists, and neonatologists discussed balancing the risk of COVID‐19 and respiratory failure to the patient, premature delivery to the neonate, potential coagulopathy associated with COVID‐19, and the need for anticoagulation with mechanical circulatory support. Ultimately, the decision was to proceed with emergency cesarean section delivery in the intensive care unit followed by peri‐partum veno‐venous extracorporeal membrane oxygenation initiation. The patient and neonate were both discharged home in stable condition. [ABSTRACT FROM AUTHOR]

Background: Recent reports have revealed better clinical outcomes for extracorporeal cardiopulmonary resuscitation (ECPR) than conventional cardiopulmonary resuscitation (CPR). In this retrospective study, we attempted to identify predictors associated with successful weaning off extracorporeal membrane oxygenation (ECMO) support after ECPR.Methods: The demographic and clinical data of 30 ECPR patients aged over 18 years treated between August 2016 and January 2019 were analyzed. All clinical data were retrospectively collected. The primary endpoint was successful weaning off ECMO support after ECPR. Patients were divided into two groups based on successful or unsuccessful weaning off ECMO support (Weaned (n = 14) vs. Failed (n = 16)).Results: Univariate logistic regression analysis showed that age, CPR duration, ECMO complications, and loss of pulse pressure significantly predicted the results of weaning off ECMO support. However, multivariate logistic regression analysis showed that only CPR duration and loss of pulse pressure independently predicted unsuccessful weaning from ECMO support.Conclusion: We conclude that long CPR duration and loss of pulse pressure after ECPR predict unsuccessful weaning from ECMO. However, unlike CPR duration, loss of pulse pressure during post-ECPR was related to subsequent management. In patients with reduced pulse pressure after ECPR, careful management is warranted because this reduction is closely associated with unsuccessful weaning off ECMO support after ECPR. [ABSTRACT FROM AUTHOR]

Genetic syndrome such as Brugada syndrome can lead to lethal ventricular arrhythmias. Cardiac sympathetic denervation has been shown to be effective in ameliorating refractory ventricular arrhythmias. We present a 33‐year‐old black female with a medical history of Brugada syndrome with an implantable cardiac defibrillator who presented with refractory ventricular tachycardia leading to cardiogenic shock, requiring extracorporeal membrane oxygenation. The patient subsequently underwent bilateral stellate ganglion sympathetic denervation in the setting of refractory ventricular arrhythmias. We present this case report to showcase that thoracoscopic bilateral cardiac sympathetic denervation can be an effective treatment option for ventricular arrhythmias refractory to medical management. [ABSTRACT FROM AUTHOR]

Background: Right ventricular failure (RVF) is a severe event that increases perioperative mortality after left ventricle assist device (LVAD) implantation. Right ventricular (RV) function is particularly affected by the LVAD speed by altering RV preload and afterload as well as the position of the interventricular septum. However, there are no studies focusing on the relationship between pump speed optimization and risk factors for the development of late RVF.Methods: Between 2015 and 2019, 50 patients received LVAD implantation at San Camillo Hospital in Rome. Of these, 38 who underwent pump speed optimization were included. Post-optimization hemodynamic data were collected. We assessed a new Hemodynamic Index (HI), calculated as follows:  HI=MAP×PCWPCVP×RPMsetRPMmax , to determine the risk of late RVF, which was defined as the requirement for rehospitalization and inotropic support.Results: Ten patients had late RVF after LVAD implantation. Five patients required diuretic therapy and speed optimization. Three patients required inotropic support with adrenaline 0.05 μg/kg/min. Two patients needed prolonged continuous venovenous hemofiltration and high dose inotropic support. Multivariate analysis revealed that a low HI (odds ratio 11.5, 95% confidence interval, 1.85-65.5, p [.003]) was an independent risk factor for late RVF after LVAD implantation.Conclusion: We demonstrated a low HI being a significant risk factor for the development of RVF after LVAD implantation. We suggest implementing HI as a decision support tool for goal-direct optimization of the device aiming to reduce the burden of late-onset RVF during the follow-up. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a rescue strategy for nonresponders to conventional CPR (CCPR) in cardiac arrest. Definitive guidelines for ECPR deployment do not exist. Prior studies suggest that arrest rhythm and cardiac origin of arrest may be variables used to assess candidacy for ECPR.Aim: To describe a single-center experience with ECPR and to assess associations between survival and physician-adjudicated origin of arrest and arrest rhythm.Methods: A retrospective review of all patients who underwent ECPR at a quaternary care center over a 7-year period was performed. Demographic and clinical characteristics were extracted from the medical record and used to adjudicate the origin of cardiac arrest, etiology, rhythm, survival, and outcomes. Univariate analysis was performed to determine the association of patient and arrest characteristics with survival.Results: Between 2010 and 2017, 47 cardiac arrest patients were initiated on extracorporeal membrane oxygenation (ECMO) at the time of active CPR. ECPR patient survival to hospital discharge was 25.5% (n = 12). Twenty-six patients died on ECMO (55.3%) while nine patients (19.1%) survived decannulation but died before discharge. Neither physician-adjudicated arrest rhythm nor underlying origin were significantly associated with survival to discharge, either alone or in combination. Younger age was significantly associated with survival. Nearly all survivors experienced myocardial recovery and left the hospital with a good neurological status.Conclusions: Arrest rhythm and etiology may be insufficient predictors of survival in ECPR utilization. Further multiinstitutional studies are needed to determine evidenced-based criteria for ECPR deployment. [ABSTRACT FROM AUTHOR]

Introduction: Disordered coagulation, clot formation and distal limb ischemia are complications of extracorporeal membrane oxygenation (ECMO) with significant morbidity and mortality. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and orthopedic surgeries to improve venous congestion and salvage ischemic flaps. To our knowledge this has not been reported in pediatric cardiac surgery or during ECMO support. We present a complex neonate whose ECMO course was complicated by distal limb ischemia for whom leech therapy was attempted.Patient and Intervention: A 2-week-old 2.7 kg infant required ECMO support secondary to perioperative multiorgan system dysfunction following repair of critical coarctation and ventricular septal defect. Despite systemic anticoagulation, his clinical course was complicated by arterial thrombus, vasopressor-induced vascular spasm and bilateral distal limb ischemia. Medicinal leech therapy was tried after initially failing conventional measures.Result: Following the third leech application, this patient developed significant hemorrhage from the web space adjacent to the left great toe. An estimated 450 ml of blood loss occurred and more than 300 ml of blood product transfusions were required. He ultimately progressed to irreversible systemic end organ dysfunction and comfort care was provided.Conclusion: The use of medicinal leech therapy in pediatric cardiac surgery may be considered to minimize the consequences of advanced limb ischemia and venous congestion. However, this should be used with caution while patients are systemically anticoagulated during ECMO support. A directed review is presented here to assist in determining optimal application and potential course of therapy. [ABSTRACT FROM AUTHOR]

Introduction: Extracorporeal membrane oxygenation (ECMO) has been used as a refractory treatment for acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19), but there has been little evidence of its efficacy. We conducted this study to share our experience using ECMO as a bridge to recovery for ARDS due to COVID-19.Methods: All adult patients who were placed on ECMO for ARDS due to COVID-19 between April 2020 and June 2020 (during the first wave of COVID-19) were identified. The clinical characteristics and outcomes of these patients were analyzed with a specific focus on the differences between patients who survived to hospital discharge and those who did not.Results: In total, 20 COVID-19 patients were included in this study. All patients were placed on veno-veno ECMO. Comparing survivors and non-survivors, older age was found to be associated with hospital mortality (p = .02). The following complications were observed: renal failure requiring renal replacement therapy (35%, n = 7), bacteremia during ECMO (20%, n = 4), coinfection with bacterial pneumonia (15%, n = 3), cannula site bleeding (15%, n = 3), stroke (10%, n = 2), gastrointestinal bleeding (10%, n = 2), and liver failure (5%, n = 1). The complications associated with patient mortality were culture-positive septic shock (p = .01), culture-negative systemic inflammatory response syndrome (p = .01), and renal failure (p = .01). The causes of death were septic shock (44%, n = 4), culture-negative systemic inflammatory response syndrome (44%, n = 4), and stroke (11%, n = 1).Conclusions: Based on our experience, ECMO can improve refractory ARDS due to COVID-19 in select patients. Proper control of bacterial infections during COVID-19 immunomodulation therapy may be critical to improving survival. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID-19) is usually mild, but patients can present with pneumonia, acute respiratory distress syndrome (ARDS), and circulatory shock. Although the symptoms of the disease are predominantly respiratory, the involvement of the cardiovascular system is common. Patients with heart failure (HF) are particularly vulnerable when suffering from COVID-19.Aim Of the Review: To examine the challenges faced by healthcare organizations, and mechanical circulatory support management strategies available to patients with heart failure, during the COVID-19 pandemic.Results: Extracorporeal membrane oxygenation (ECMO) can be lifesaving in patients with severe forms of ARDS, or refractory cardio-circulatory compromise. The Impella RP can provide right ventricular circulatory support for patients who develop right side ventricular failure or decompensation caused by COVID-19 complications, including pulmonary embolus. HT are reserved for only those patients with a high short-term mortality. LVAD as a bridge to transplant may be a viable strategy to get at-risk patients home quickly. Elective LVAD implantations have been reduced and only patients classified as INTERMACS profile 1 and 2 are being considered for LVAD implantation. Delayed recognition of LVAD-related complications, misdiagnosis of COVID-19, and impaired social and psychological well-being for patients and families may ensue. Remote patient care with virtual or telephone contacts is becoming the norm.Conclusions: HF incidence, prevalence, and undertreatment will grow as a result of new COVID-19-related heart disease. ECMO should be reserved for highly selected cases of COVID-19 with a reasonable probability of recovery. Special considerations are needed for patients with advanced HF, including those supported by durable LVADs. [ABSTRACT FROM AUTHOR]

Background: The current coronavirus disease 2019 (COVID‐19) pandemic has a huge impact on society and the economy and represents one of the biggest challenges for healthcare systems all over the world. Reports from healthcare institutions in different countries show a variety of crisis exit strategies. Methods: The following is a review and update of the situation and crisis management in Zürich and Switzerland with a special focus on the impact on the cardiac surgery program and extracorporeal membrane oxygenation (ECMO)‐therapy in COVID‐19. Results: Regional and national measures had avoided the collapse of the health system in Switzerland. There was a reduction of over 50% of the surgical and transcatheter caseload during the first wave of the pandemic. Twenty‐three ECMO devices, 150 oxygenators, and more than 300 different cannulas were at our disposal. Between March and May 2020, nine COVID‐19 patients were treated by us with ECMO‐therapy. Three patients were transported by us from distant institutions. Median age at ECMO implantation was 59 years. Two patients died on support. Conclusions: Measures to prevent a collapse of the healthcare system were effective. Our local ECMO‐Program on the ongoing COVID‐19 pandemic has proven to be a useful tool to control mortality and organ failure in critically ill patients. [ABSTRACT FROM AUTHOR]

Background: To share the results of a web-based expert panel discussion focusing on the management of acute and chronic aortic disease during the coronavirus (COVID-19) pandemic.Methods: A web-based expert panel discussion on April 18, 2020, where eight experts were invited to share their experience with COVID-19 disease touching several aspects of aortic medicine. After each talk, specific questions were asked by the online audience, and results were immediately evaluated and shared with faculty and participants.Results: As of April 18, 73.3% answered that more than 200 patients have been treated at their respective settings. Sixty-four percent were reported that their hospital was well prepared for the pandemic. In 57.7%, the percentage of infected healthcare professionals was below 5% whereas 19.2% reported the percentage to be between 10% and 20%. Sixty-seven percent reported the application of extracorporeal membrane oxygenation in less than 2% of COVID-19 patients whereas 11.8% reported application in 5%-10% of COVID-19 patients. Thirty percent of participants reported the occurrence of pulmonary embolism in COVID-19 patients. Three percent reported to have seen aortic ruptures in primarily elective patients having been postponed because of the anticipated need to provide sufficient ICU capacity because of the pandemic. Nearly 70% reported a decrease in acute aortic syndrome referrals since the start of the pandemic.Conclusion: The current COVID-19 pandemic has-besides the stoppage of elective referrals-also led to a decrease of referrals of acute aortic syndromes in many settings. The reluctance of patients seeking medical help seems to be a major driver. The number of patients, who have been postponed due to the provisioning of ICU resources but having experienced aortic rupture in the waiting period, is still low. Further, studies are needed to learn more about the influence that the COVID-19 pandemic has on the treatment of patients with acute and chronic aortic disease. [ABSTRACT FROM AUTHOR]

Providing complex therapies such as extracorporeal membrane oxygenation (ECMO) during outbreaks of infectious diseases has singular challenges. The impact of the SARS‐CoV‐2 pandemic has implied a mentality change by force of circumstances, and cardiac surgery has not been stranger to this trend. The need to treat critically ill patients with an unknown evolution has compelled cardiovascular surgeons to decide whether or not to implant an ECMO system, despite the limited scientific evidence available in the context of COVID‐19. To add some confusion, doubts were raised about its potential deleterious outcome in COVID‐19 patients, due to its effect on lymphocyte counts and interleukin‐6 concentrations. The care of the critically ill patient in a moment of national emergency in Spain took precedence over those possible formal doubts. The Spanish perspective on ventricular assist devices during and after the COVID‐19 pandemic, focused on ECMO as a particular case of mechanical circulatory support, is presented. We address both the challenges posed by the pandemic and the organizational model established in Spain; changes in ECMO therapy and some lessons learned for the next outbreaks are also described. It is not about reinventing the wheel in each country; it is enough to learn from experience and take advantage of the knowledge generated by those who have already gone through similar situations in our environment. [ABSTRACT FROM AUTHOR]

Background: Ebstein's anomaly (EA) is a kind of congenital heart disease, which is currently widely treated by cone reconstruction. However, the prediction of postoperative recovery is still challenging. Methods: A retrospective analysis was performed on EA cases undergoing cone reconstruction from January 2010 to January 2016. Univariate and multivariate logistic regression analyses were performed, with postoperative adverse events defined as dependent variable and pre‐ and intraoperative parameters defined as independent variables. The predictive capacity of preoperative percutaneous oxygen saturation (SPO2) and Great Ormond Street (GOS) score was evaluated using areas under the curve of the receiver operating characteristic (ROC). Results: Preoperative SPO2 was 95.7 ± 5.20%. Cardiopulmonary bypass, aortic cross‐clamp, postoperative mechanical ventilation, and hospitalization time were 101.7 ± 28.26 min, 60.9 ± 18.04 min, 16 h (8, 22), and 8 days (7, 11), respectively. The incidence of total postoperative adverse events, including low cardiac output syndrome, mechanical ventilation more than 3 days, postoperative hospitalization more than 2 weeks, postoperative reintubation, extracorporeal membrane oxygenation assistance, and death, was 13.1% (n = 13). Low preoperative SPO2 (p =.001, odds ratio [OR] = 0.834), GOS score (p =.021, OR = 0.368), and cardiopulmonary bypass time (p =.034, OR = 1.021) were risk factors for adverse events. Multivariate logistic regression analysis showed that low preoperative SPO2 (p =.002, OR = 0.846) and GOS score (p =.043, OR = 0.577) were independent risk factors for adverse events. The areas of SPO2 and GOS score under the ROC curve were 0.764 and 0.740, respectively. Conclusions: Low preoperative SPO2 and GOS score were predictors of adverse events after cone reconstruction, and SPO2 was more convenient and objective than the GOS score. [ABSTRACT FROM AUTHOR]

Background: The utilization of venoarterial extracorporeal membrane oxygenation (VA‐ECMO) as a life‐supporting therapy has increased exponentially over the last decade. As more patients receive and survive ECMO, there are a number of unanswered clinical questions about their long‐term prognosis and organ function including the need for long‐term dialysis. Methods: We aimed to utilize over 208 patient‐years of follow‐up data from our large institutional cohort of VA‐ECMO patients to determine the incidence of requiring VA‐ECMO support on the need for renal replacement therapy after discharge (LT‐dialysis). This retrospective review included all adult VA‐ECMO patients at our institution from January 2014 to October 2018 (N = 283). Results: Out of the 99 (35%) survivors, 88 (89%) did not require LT‐dialysis of any duration after discharge from the index hospitalization. Patients who required VA‐ECMO for decompensated cardiogenic shock were more likely to need LT‐dialysis (p =.034), and those who required renal replacement therapy during VA‐ECMO (N = 27) also had a higher incidence of LT‐dialysis (33%). Conclusion: Overall, these data suggest there is a low incidence of long‐term dialysis dependence among survivors of VA‐ECMO support. Worries about the potential long‐term detrimental effect of VA‐ECMO should not preclude patients from receiving this life‐saving support. [ABSTRACT FROM AUTHOR]

Granulomatosis with polyangiitis (GPA, also known as Wegener's granulomatosis) is a type of systematic vasculitis that primarily involves the lung and kidney. Diffuse alveolar hemorrhage (DAH) and associated acute respiratory failure are uncommon but devastating complications of GPA. Experience in using extracorporeal membrane oxygenation (ECMO) to manage DAH caused by GPA is limited. We report two GPA patients with DAH that were successfully managed using ECMO support. Examining 13 cases identified in the literature and two of our own, we observed that most patients experienced rapid deterioration in respiratory function in conjunction with a precedent respiratory infection. All 15 patients received veno‐venous ECMO support. The median duration of ECMO support was 11 days (interquartile range: 7.5–20.75 days). Bleeding was the most common complication, seen in four (26.7%) cases. All patients were successfully weaned off ECMO after a median length of hospital stay of 42 days (interquartile range: 30–78 days). We demonstrated that the use of ECMO is a reasonable and effective support option in the management of GPA patients with DAH. The risk of bleeding is high but maybe reduced using a lower anticoagulation goal. [ABSTRACT FROM AUTHOR]

A 61‐year‐old woman with acute myocardial infarction (MI), cardiogenic shock, and Impella CP support underwent emergency coronary artery bypass grafting. Postoperatively venous‐arterial extracorporeal membrane oxygenation (va‐ECMO) became necessary, followed by Impella 5.0 insertion on 7th postoperative day (POD), the addition of right ventricular support by TandemHeart due to inadequate flow of Impella system, which then allowed for va‐ECMO weaning. Impella und TandemHeart were removed on 14th POD, 31st POD, respectively. Biventricular decompensation following MI was successfully treated by a sequence of different mechanical circulatory support systems allowing an adaptive weaning strategy. [ABSTRACT FROM AUTHOR]

Temporary mechanical circulatory support (MCS) systems are indicated to stabilize hemodynamically decompensating patients in cardiogenic shock refractory to medical management. These devices are currently used as short‐term hemodynamic support to facilitate organ recovery or bridge to definitive therapy with durable MCS or heart transplantation. We present the sequential use of intra‐aortic balloon pump, Impella 5.5®, and venoarterial extracorporeal membrane oxygenation as a bridge to heart–liver–kidney transplantation. The patient was supported for 78 days on Impella 5.5 and 95 days total temporary MCS. He had an uncomplicated postoperative course after triple‐organ transplantation and was stable with no signs of rejection at 1‐, 3‐, 6‐, and 12‐month follow‐up. [ABSTRACT FROM AUTHOR]

Critical airway stenosis is challenging for surgeons and anesthesiologists to secure a reliable airway for ventilation. The use of venovenous (VV)‐extracorporeal membrane oxygenation (ECMO) has been described as a strategy to provide adequate gas exchange in such instances. We present a case of a young female with a complex paratracheal mass significantly compressing the trachea; a planned intraoperative VV‐ECMO was instituted to allow safe orotracheal intubation of a double‐lumen endotracheal tube for lung isolation and tumor resection. [ABSTRACT FROM AUTHOR]

Background: This study compared outcomes of patients bridged with extracorporeal membrane oxygenation (ECMO) to orthotopic heart transplantation (OHT) following the recent heart allocation policy change. Methods: The United Network of Organ Sharing Registry (UNOS) database was queried to examine OHT patients between 2010 and 2020 that were bridged with ECMO. Waitlist outcomes and 1‐year posttransplant survival were compared between patients waitlisted and/or transplanted before and after the heart allocation policy change. Secondary outcomes included posttransplant stroke, renal failure, and 1‐year rejection. Results: A total of 285 waitlisted patients were included, 173 (60.7%) waitlisted under the old policy and 112 (39.3%) under the new policy. New policy patients were more likely to receive OHT (82.2% vs. 40.6%), and less likely to be removed from the waitlist due to death or clinical deterioration (15.0% vs. 41.3%; both p <.001). A total of 165 patients bridged from ECMO to OHT were analyzed, 72 (43.6%) transplanted during the old policy and 93 (56.3%) under the new. Median waitlist time was reduced under the new policy (4 days [interquartile range {IQR}: 2–6] vs. 47 days [IQR: 10–228]). Postoperative renal failure was higher in the new policy group (23% vs. 6%; p =.002), but rates of stroke and 1‐year acute rejection were equivalent. One‐year survival was lower the new policy but was not significant (79.8% vs. 90.3%; p =.3917). Conclusions: The UNOS heart allocation policy change has resulted in decreased waitlist times and higher likelihood of transplant in patients supported with ECMO. Posttransplant 1‐year survival has remained comparable although absolute rates are lower. [ABSTRACT FROM AUTHOR]

The mortality rate after the development of postinfarction ventricular septal defect (VSD) remains high, despite progress in pharmacologic therapy, invasive cardiology, and surgical techniques. We present three cases of preoperative venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgical repair in patients with cardiogenic shock who would otherwise require emergent cardiac surgery with an associated risk. Two patients were discharged, whereas the third patient died due to pulmonary artery rupture after a right ventricular assist device implantation, despite the fact that he had a successful bridge to reparative surgery and VSD repair. Finally, a review of the current literature concerning the use of preoperative venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgery is provided. [ABSTRACT FROM AUTHOR]

Background: Reintervention after transcatheter edge to edge repair using MitraClip is still challenging. We aimed to report our experience in reinterventions after MitraClip procedures and describe the outcomes. Methods: From 2012 to 2020, 167 patients had a transcatheter edge to edge repair; 10 of them needed reinterventions. At the time of the first MitraClip, the median EuroSCORE was 4.29 (2.62–7.52), and the ejection fraction was 30 (20–40)%. Results: Emergency mitral valve replacement (MVR) was performed in two patients, elective MVR in three, cardiac transplantation in two, and repeat clipping in threepatients. The median time from MitraClip to the reintervention was 4.5 (2–13) months. One patient required extracorporeal membrane oxygenation support after elective MVR. Repeat clipping failed to control mitral regurgitation grade in all patients. Clip detachment was reported in five patients (50%). The median follow‐up after the reintervention was 19.5 (9–75) months, and mortality occurred in two patients who had repeat clipping (20%). Conclusions: MVR after MitraClip is feasible with low morbidity and mortality. Repeat mitral valve clipping had a high failure rate. Mitral repair was not feasible in all patients in our series, and the use of MitraClip to delay surgical interventions may not be feasible if mitral repair is an option. [ABSTRACT FROM AUTHOR]

Background: The use of extracorporeal circulation (ECC) for intraoperative cardiopulmonary support during lung transplantation has been increasing in the recent years. Our group previously described a novel hybrid extracorporeal membrane oxygenation (ECMO) circuit for use in lung transplantation. Technique: Our approach for intraoperative management of our novel hybrid ECMO circuit for lung transplantation is driven by two main goals: The first is to deliver management that ensures an appropriate balance between the native and ECMO cardiac outputs in order to provide a stable environment that promotes attenuation of ischemic‐reperfusion injury during implantation. The second is to provide a stable hemodynamic environment that results in an appropriate global perfusion guided by multiple monitors and an organ systems‐based approach during implantation. Comments: Our novel technique for intraoperative management of this circuit during lung transplantation is described. [ABSTRACT FROM AUTHOR]

Background: Patients scheduled for surgery after unsuccessful MitraClip® intervention present increasingly with multiple comorbidities, and they are often referred to the heart team to suggest the most appropriate intervention. The publication of successful results of initial patient cohorts treated with the MitraClip device has resulted in recruitment of more seriously ill patients, who otherwise would have been denied catheter‐based/surgical treatment. There has been increasingly reports on conventional surgery after failed mitral valve repair with the MitraClip device. However, data on such procedures remain scarce and mostly focused on individual case studies. The inevitable increase in use of MitraClip, however, will raise the number of patients in need of surgery post MitraClip, making it imperative for surgeons to understand challenges and outcome data related with surgery in this patient cohort. We present our long‐term institutional experience with surgery after MitraClip intervention in highest risk patients. Methods: Eighteen patients underwent surgery of the mitral valve at our Institution between January 2015 and June 2020. These patients developed recurrent mitral regurgitation grade more than 2° at various intervals after MitraClip. Mitral valve repair was performed where possible and gross examination Valve/MitraClip were intra‐operatively documented. Implanted MitraClip devices were analyzed histopathologically to evaluate the healing process and rule out inflammation. Regular patient follow‐up was performed. Results: Mean patient age was 74 (±9 years) and MitraClip implantation was performed at various tertiary institutions. Sixteen out of eighteen (16/18) patients received mitral valve replacement, whereas the remaining two patients received mitral valve repair and extracorporal membrane oxygenation, respectively. Four patients died of sepsis and intractable multi organ failure in‐hospital. The remaining patients were discharged alive out of hospital to different rehabilitation centers. Follow‐up was complete in all patients. Conclusions: Surgery is demanding when patients require surgery for persistent or recurrent mitral regurgitation after MitraClip therapy and can be successfully implemented as a possible therapy option for selective cases as an interdisciplinary approach despite calculated high perioperative mortality risk. These patients should not be denied surgery outright. [ABSTRACT FROM AUTHOR]