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Introduction. Extracorporeal membrane oxygenation (ECMO) support for severe acute respiratory distress syndrome (ARDS) is nowadays widely used with notable results on the overall survival as reported in the ELSO registry near to 55% at 90 days. This is the reason why ECMO teams force the use of this extreme technique to several populations, even though there is still a lack of data about its use on hematological patients. Case Report. A 39-year-old woman without a history of previous diseases, but a new diagnosis of acute myeloblastic leukemia (AML) was admitted to intensive care unit (ICU) for worsening hypoxia and respiratory acidosis, presenting an ARDS with Pa O 2 / Fi O 2 < 100 in spontaneous breathing treated with noninvasive ventilation via full-face mask. Meanwhile, chemotherapy was started leading to a severe bone marrow aplasia that was managed with multiple blood and platelet transfusions. These conditions did not allow physicians to start any invasive approaches. After 14 days, ARDS worsened whereas bone marrow recovered, making possible the beginning of an invasive mechanical ventilation, with low positive end-expiratory pressure and a low tidal volume. Moreover, an immediate extracorporeal CO2 removal (ECCO2R) therapy was added. Despite these efforts, no improvement was achieved, and that is why venovenous ECMO throughout femoral-jugular cannulation was applied. A full protective lung ventilation by ultralow tidal volumes was guaranteed. After 2 weeks of ECMO, a gradual weaning from ECMO support was started and completed after two days. No ECMO-related complications were registered. In the end, the patient started her weaning from the mechanical ventilation and reached 12 hours of spontaneous ventilation in oxygen therapy. Discussion. ECMO is used as a rescue therapy in patients affected by severe respiratory failure with life-threatening hypoxia and respiratory acidosis nonresponsive to other maneuvers. However, immunosuppression and coagulopathies of hematological malignancies are considered relative contraindications for ECMO, while long-lasting respiratory failure represents another relative contraindication to extracorporeal support. ECMO could be a valid option to improve the survival of hematological patients with severe ARDS and thrombocytopenia, and management could change case by case, even if high incidence of recurrency. [ABSTRACT FROM AUTHOR]

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]

We present here a unique case in which a 63-year-old man developed diffuse coronary vasospasm on postoperative day (POD) 1 following uneventful aortic valve replacement, replacement of ascending aorta, and coronary artery bypass. Subsequent emergent coronary angiogram demonstrated diffuse native coronary artery vasospasm that was only transiently responsive to intracardiac nitroglycerin, resulting in persistent cardiogenic shock and severe biventricular dysfunction. The patient was, thus, placed on femoral-femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) with Impella support. This strategy allowed the weaning of vasopressors and enabled the resolution of the vasospasm. The patient was ultimately discharged on POD 17 without further complications. This case demonstrates our management strategy to provide life-saving support for patients facing postcardiac surgery refractory vasospasm. [ABSTRACT FROM AUTHOR]

Legionella bozemanii pneumonia is a rare form of Legionnaires' disease caused by the bacterium Legionella bozemanii. It is well known to cause pneumonia in immunocompromised patients and has rarely been reported in immunocompetent hosts. We describe a case of a 59-year-old immunocompetent female presented with pneumonia, acute respiratory failure, acute respiratory distress, and septic shock, who was treated with azithromycin, goal-directed resuscitation, and extracorporeal membrane oxygenation (ECMO) but did not survive. Clinicians should have high suspicion of rare legionella pathogens as causative agents for pneumonia. [ABSTRACT FROM AUTHOR]

Objective. We investigated the potential use of galectin-3 (Gal-3) as a prognostic indicator for patients with cardiogenic shock and developed a predictive mortality model for venoarterial extracorporeal membrane oxygenation (VA-ECMO). Methods. We prospectively studied patients (survivors and nonsurvivors) who received VA-ECMO for cardiogenic shock from 2019 to 2021. We recorded baseline data, Gal-3, and B-type natriuretic peptide (BNP) before ECMO and 24–72 h after ECMO. We used multivariable logistic regression to analyze significant risk factors and construct a VA-ECMO death prediction model. Receiver operating characteristic (ROC) curves were plotted to assess the predictive efficacy of the model. Results. We enrolled 73 patients with cardiogenic shock who received VA-ECMO support; 38 (52.05%) died in hospital. The median age was 57 years (interquartile range (IQR): 48–67 years); the median duration of ECMO therapy was 5.8 days (IQR: 4.62–7.57 days); and the median intensive care unit stay was 19.04 days (IQR: 13.92–26.15 days). Compared with the nonsurvivors, survivors had lower acute physiology and chronic health evaluation (APACHE) II scores (p < 0.001), increased left ventricular ejection fraction (p < 0.05), lower Gal-3 levels at 24 and 72 h (both p = 0.001), lower BNP levels at 24 and 72 h (both p = 0.001), and higher platelet counts (p = 0.009). Further multivariable analysis showed that APACHE II score, BNP-T72, and Gal-3-T72 were independent risk factors for death in VA-ECMO patients. Gal-3 and BNP were positively correlated (p < 0.05) and decreased significantly during ECMO treatment. The areas under the ROC curve (AUC) for APACHE II score, Gal-3-T72, and BNP-T72 were 0.687, 0.799, and 0.723, respectively. We constructed a combined prediction model with an AUC of 0.884 (p < 0.01). Conclusion. Gal-3 may serve as a prognostic indicator for patients receiving VA-ECMO for cardiogenic shock. The combined early warning score is a simple and effective tool for predicting mortality in VA-ECMO patients. [ABSTRACT FROM AUTHOR]

Background. Pulmonary veno-occlusive disease (PVOD) is a rare form of pulmonary arterial hypertension characterized by diffuse venous vasculopathy and increased pulmonary vascular resistance resulting in right-sided heart failure. Case Presentation. A 22-year-old female patient started to have dyspnea with minimal effort and was diagnosed to have pre-capillary pulmonary hypertension (PH) with right-sided heart failure. Initially, she was diagnosed to have idiopathic PH. She developed life-threatening pulmonary oedema and cardiogenic shock after pulmonary vasodilator therapy. A genetic study was done and revealed the eukaryotic translation initiation factor 2 alpha kinase 4 (EIF2AK4) gene on chromosome 15, which was diagnostic to heritable PVOD. After failure to achieve hemodynamic stabilization with conventional cardiopulmonary support measures, extracorporeal membrane oxygenation (ECMO) supported her till bilateral lung transplantation, which was unfortunately complicated by acute graft rejection. After a prolonged intensive care unit stay with 4-month ECMO support, the second bilateral lung transplantation was done, and the patient survived and was discharged. Conclusions. Clinical recognition of PVOD is crucial due to its challenging diagnosis, need for genetic study, rapid deterioration with pulmonary vasodilators, and bad prognosis. Lung transplantation is the definitive treatment for eligible candidates. [ABSTRACT FROM AUTHOR]

Introduction. Large thrombi in the inferior vena cava pose a high risk for a pulmonary embolism. Percutaneous extracorporeal circulation-based vacuum-assisted thrombus aspiration is a viable option for removal. Wall adherence of thrombotic material can compromise procedural success. Case Report. A 46-year-old female presented with a subtotal thrombotic occlusion of the inferior vena cava and the proximal right common iliac vein after weaning from extracorporeal life support. Due to severe wall adherence of the thrombotic material, the patient was treated with the combination of percutaneous extracorporeal circulation-based thrombus aspiration using the AngioVac system and a rotational thrombectomy device. [ABSTRACT FROM AUTHOR]

Background. Pulmonary veno-occlusive disease (PVOD) is a rare form of pulmonary arterial hypertension characterized by diffuse venous vasculopathy and increased pulmonary vascular resistance resulting in right-sided heart failure. Case Presentation. A 22-year-old female patient started to have dyspnea with minimal effort and was diagnosed to have pre-capillary pulmonary hypertension (PH) with right-sided heart failure. Initially, she was diagnosed to have idiopathic PH. She developed life-threatening pulmonary oedema and cardiogenic shock after pulmonary vasodilator therapy. A genetic study was done and revealed the eukaryotic translation initiation factor 2 alpha kinase 4 (EIF2AK4) gene on chromosome 15, which was diagnostic to heritable PVOD. After failure to achieve hemodynamic stabilization with conventional cardiopulmonary support measures, extracorporeal membrane oxygenation (ECMO) supported her till bilateral lung transplantation, which was unfortunately complicated by acute graft rejection. After a prolonged intensive care unit stay with 4-month ECMO support, the second bilateral lung transplantation was done, and the patient survived and was discharged. Conclusions. Clinical recognition of PVOD is crucial due to its challenging diagnosis, need for genetic study, rapid deterioration with pulmonary vasodilators, and bad prognosis. Lung transplantation is the definitive treatment for eligible candidates. [ABSTRACT FROM AUTHOR]

Background. In patients with severe respiratory failure from COVID-19, extracorporeal membrane oxygenation (ECMO) treatment can facilitate lung-protective ventilation and may improve outcome and survival if conventional therapy fails to assure adequate oxygenation and ventilation. We aimed to perform a confirmatory propensity-matched cohort study comparing the impact of ECMO and maximum invasive mechanical ventilation alone (MVA) on mortality and complications in severe COVID-19 pneumonia. Materials and Methods. All 295 consecutive adult patients with confirmed COVID-19 pneumonia admitted to the intensive care unit (ICU) from March 13th, 2020, to July 31st, 2021 were included. At admission, all patients were classified into 3 categories: (1) full code including the initiation of ECMO therapy (AAA code), (2) full code excluding ECMO (AA code), and (3) do-not-intubate (A code). For the 271 non-ECMO patients, match eligibility was determined for all patients with the AAA code treated with MVA. Propensity score matching was performed using a logistic regression model including the following variables: gender, P/F ratio, SOFA score at admission, and date of ICU admission. The primary endpoint was ICU mortality. Results. A total of 24 ECMO patients were propensity matched to an equal number of MVA patients. ICU mortality was significantly higher in the ECMO arm (45.8%) compared with the MVA cohort (16.67%) (OR 4.23 (1.11, 16.17); p = 0.02). Three-month mortality was 50% with ECMO compared to 16.67% after MVA (OR 5.91 (1.55, 22.58); p < 0.01). Applied peak inspiratory pressures (33.42 ± 8.52 vs. 24.74 ± 4.86 mmHg; p < 0.01) and maximal PEEP levels (14.47 ± 3.22 vs. 13.52 ± 3.86 mmHg; p = 0.01) were higher with MVA. ICU length of stay (LOS) and hospital LOS were comparable in both groups. Conclusion. ECMO therapy may be associated with an up to a three-fold increase in ICU mortality and 3-month mortality compared to MVA despite the facilitation of lung-protective ventilation settings in mechanically ventilated COVID-19 patients. We cannot confirm the positive results of the first propensity-matched cohort study on this topic. This trial is registered with NCT05158816. [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]

Pregnant women are especially vulnerable to coronavirus disease 2019 (COVID-19). We present a twin pregnancy case with acute respiratory distress syndrome following COVID-19 infection at 19 weeks. The patient's ARDS was successfully managed with veno-venous extracorporeal membrane oxygenation (VV ECMO). She recovered completely and delivered healthy twins. [ABSTRACT FROM AUTHOR]

Introduction. Evidence regarding the impact of prophylactic implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for elective high-risk percutaneous coronary intervention (PCI) is limited. The purpose of this paper is to evaluate the outcome during index hospitalization and 3 years after interventions. Methods. This is an observational retrospective study including all patients undergoing elective, high-risk PCI and receiving VA-ECMO for cardiopulmonary support. Primary endpoints were in-hospital and 3- year major adverse cardiovascular and cerebrovascular event (MACCE) rates. Secondary endpoints were vascular complications, bleeding, and procedural success. Results. Nine patients were included in total. All patients were considered inoperable by the local heart team, and 1 patient had a previous coronary artery bypass graft (CABG). All patients were hospitalized for an acute heart failure episode 30 days before the index procedure. Severe left ventricular dysfunction was present in 8 patients. The main target vessel was the left main coronary artery in 5 cases. Complex PCI techniques were used: bifurcations with 2 stents in 8 patients, rotational atherectomy was performed in 3, and coronary lithoplasty in 1 case. PCI was successful in all of the patients with revascularization of all target and additional lesions. Eight of the 9 patients survived for at least 30 days after the procedure, and 7 patients survived for 3 years after the procedure. Regarding the complication rate, 2 patients suffered from limb ischemia and were treated by an antegrade perfusion, 1 patient had a femoral perforation that needed surgical repair, 6 patients had a hematoma, 5 patients had a significant drop in hemoglobin of more than 2 g/dl and received blood transfusions, 2 patients were treated for septicemia, and 2 patients needed hemodialysis. Conclusions. Prophylactic use of VA-ECMO in elective patients is an acceptable strategy for revascularization by high-risk coronary percutaneous interventions with good long-term outcomes for patients considered inoperable when a clear clinical benefit is expected. Regarding the potential risk of complications due to a VA-ECMO system, the selection of candidates in our series was based on a multiparameter analysis. The two main triggers in favor of prophylactic VA-ECMO in our studies were the presence of a recent heart failure episode and the high probability of periprocedural prolonged impairment of the coronary flow through the major epicardial artery. [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]

Objectives: To compare two different forms of mechanical circulatory support (MCS) in patients with complex high-risk indicated PCI (CHIP): the Impella CP system and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).Background: To prevent hemodynamic instability in CHIP, various MCS systems are available. However, comparable data on different forms of MCS are not at hand.Methods: In this multicenter observational study, we retrospectively evaluated all CHIP procedures with the support of an Impella CP or VA-ECMO, who were declined surgery by the heart team. Major adverse cardiac events (MACE), mortality at discharge, and 30-day mortality were evaluated.Results: A total of 41 patients were included, of which 27 patients were supported with Impella CP and 14 patients with VA-ECMO. Baseline characteristics were well-balanced in both groups. No significant difference in periprocedural hemodynamic instability was observed between both groups (3.7% vs. 14.3%; p = 0.22). The composite outcome of MACE showed no significant difference (30.7% vs. 21.4%; p = 0.59). Bleeding complications were higher in the Impella CP group, but showed no significant difference (22.2% vs. 7.1%; p = 0.22) and occurred more at the non-Impella access site. In-hospital mortality was 7.4% in the Impella CP group versus 14.3% in the VA-ECMO group and showed no significant difference (p = 0.48). 30-Day mortality showed no significant difference (7.4% vs. 21.4%; p = 0.09).Conclusions: In patients with CHIP, there were no significant differences in hemodynamic instability and overall MACE between VA-ECMO or Impella CP device as mechanical circulatory support. Based on this study, the choice of either VA-ECMO or Impella CP does not alter the outcome. [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]

What is known and objective: The presence of extracorporeal membrane oxygenation (ECMO) is suggested to further exacerbate the pharmacokinetics (PK) alterations that occur during critical illness. The objectives of this study were to determine the population PK model of polymyxin B in critically ill patients with or without ECMO support investigated the influence of ECMO on PK variability and to identify an optimal dosing strategy. Methods: Forty‐four critically ill patients were enrolled, including eight patients with ECMO support. Eight serial serum samples were collected from each patient at steady state. The population PK was determined using NONMEM and Monte Carlo simulation was performed to evaluate the exposures of different dosing regimens. Results: The PK analyses included 342 steady‐state concentrations and a two‐compartment model was optimal for polymyxin B PK data modelling. In the final model, creatinine clearance (CLCR) was the significant covariate on CL (typical value 1.27 L/h; between‐subject variability 15.1%) and ECMO did not show a significant impact on the polymyxin B PK. Additionally, we found that the PK parameter estimates of patients with and without ECMO support were mostly similar. Based on Monte Carlo simulations, the dose escalation of polymyxin B in patients with increased CLCR improved the probability of achieving required exposure. For patients with CLCR ≤ 120 ml/min, a dosage regimen of 100 mg every 12 h may represent the optimal regimen at an MIC of 1 mg/L. What is new and conclusion: The impact of ECMO on the polymyxin B PK is likely to be minimal. Our study showed a potential relationship between CLCR and polymyxin B CL, and the dose of polymyxin B should be adjusted in patients with increased CLCR. [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. Pericardiocentesis is a therapeutic lifesaving intervention for patients presenting with cardiogenic shock due to pericardial effusion with signs of tamponade. Pericardial decompression syndrome (PDS) is a rare fatal complication that may occur after pericardiocentesis. Case Presentation. We report a case of a patient with idiopathic primary pulmonary hypertension who presented with massive pericardial effusion complicated with rapid hemodynamic and respiratory deterioration. Gradual therapeutic pericardiocentesis was done but progressive circulatory collapse occurred. Emergent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was applied. Echocardiography revealed severe right ventricle failure. Unfortunately, the patient developed acute progressive thrombocytopenia and bilaterally diffuse subarachnoid hemorrhage after 4 days of ECMO support. Conclusions. Therapeutic pericardiocentesis can be occasionally fatal in cases of significant pulmonary hypertension with massive pericardial effusion when complicated by pericardial decompression syndrome. Acute significant thrombocytopenia may occur with VA-ECMO support resulting in fatal bleeding. [ABSTRACT FROM AUTHOR]

Coronary artery spasm after coronary artery bypass grafting is a rare but life-threatening condition. Herein, we report the case of a 77-year-old man who received off-pump coronary artery bypass grafting. An hour after surgery, there was a sudden hemodynamic compromise due to coronary artery spasm, prompting emergent coronary angiography with extracorporeal membrane oxygenation support. Because the angiography results showed diffuse severe spasm of the entire native coronary artery, the patient was treated with an intracoronary injection of vasodilators. The patient recovered in 7 days with mechanical support, catecholamines, and vasodilators, and he was discharged on postoperative day 30. Although coronary artery spasm after off-pump coronary artery bypass surgery is a rare condition, it must be suspected when sudden circulatory collapse occurs. [ABSTRACT FROM AUTHOR]

What is known and objective: Many severe intoxications occur with substances with no specific antidote, which is why methods of extracorporeal elimination represent a particularly useful and even critical component in their management. The purpose of this review is to summarize the accumulating evidence and clinical results from the application of CytoSorb hemoadsorption therapy in patients with severe intoxications. Comment: The technology represents a promising technique with an increasing number of publications in a variety of severe intoxication scenarios suggesting that early intervention might provide rapid substance removal with subsequent overall clinical improvement. What is new and conclusion: Given the tremendous challenges in performing prospective, randomized trials in this field, the strong safety profile of the device and the high acuity of these life‐threatening situations, CytoSorb should be considered as a therapeutic option in severe intoxications, particularly when direct antidotes are not available. However, further clinical data are desirable to provide precise recommendations. [ABSTRACT FROM AUTHOR]

Anti-GBM disease is a rare vasculitis that causes rapid progressive glomerulonephritis and pulmonary haemorrhage. It is usually an adult diagnosis with isolated paediatric cases reported. Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy mainly affecting adults that causes multiorgan ischaemia, microangiopathic haemolytic anaemia, and thrombocytopenia. We present the first paediatric case of concurrent anti-GBM disease and TTP. A 14-year-old boy presented with acute kidney failure and severe pulmonary haemorrhage due to anti-GBM disease, confirmed on auto-antibody testing. There was thrombocytopenia and moderately low ADAMTS13 activity suggestive of TTP. The renal prognosis was poor with a need for dialysis. He was severely unwell with pulmonary haemorrhages requiring the use of extracorporeal membrane oxygenation (ECMO). His disease was treated with corticosteroids, plasma exchange (PEX), rituximab, and cyclophosphamide, resulting in remission. Anti-GBM disease is rare in children but should be considered in those presenting with acute kidney injury, particularly where there has been exposure to pulmonary irritants. An aggressive presentation warrants aggressive treatment with methylprednisolone, PEX, and cyclophosphamide. Rituximab may benefit patients that have concurrent TTP. TTP may exacerbate pulmonary disease, but complete respiratory recovery is possible. Disease relapse is rare in the paediatric age group, and these patients are candidates for kidney transplantation. [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]

Amniotic fluid embolism (AFE) is a rare and often fatal complication of pregnancy that occurs during the puerperium. The low incidence of AFE has resulted in few large studies, which makes evidence-based management of AFE challenging. The use of extracorporeal membrane oxygenation (ECMO) has been reported but is limited by availability and challenges managing anticoagulation. In this report, we detail the case of a 29-year-old female who suffered from an AFE leading to cardiac arrest and disseminated intravascular coagulopathy. She was treated with protocolized A-OK (adenosine, ondansetron, and ketorolac), emergency c-section, cardiopulmonary resuscitation, massive blood transfusion, and rotational thromboelastometry-guided ECMO, allowing her to forgo initial anticoagulation. After a prolonged rehabilitation with initial poor neurological status, she made a complete recovery. In this report, we describe the protocols that contributed to her recovery and detail management of complicated AFE for other clinicians. [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: In this study, we evaluate the previously reported novel Minnesota Score for association with in-hospital mortality and allocation of venovenous extracorporeal membrane oxygenation in patients with acute respiratory distress syndrome with or without SARS-CoV-2 pneumonia.Methods: This was a retrospective cohort study across four extracorporeal membrane oxygenation centers in Minnesota. Logistic regression was used to assess the relationship between the scores and in-hospital mortality, duration of ECMO cannulation, and discharge disposition. Priority groups were established statistically by maximizing the sum of sensitivity and specificity and compared to the previous qualitatively established priority groups.Results: Of 124 patients included in the study, 38% were treated for COVID-19 acute respiratory distress syndrome. The median age was 48 years, and 73% were male. The in-hospital mortality rate was 38%. The Minnesota Score was significantly associated with in-hospital mortality only (OR 1.13, p=0.02). Statistically determined cut points were similar to qualitative cut points. SARS-CoV-2 status did not change the findings.Conclusions: In our patient cohort, the Minnesota Score is associated with increased mortality. With further validation, proposed priority groups could be utilized for allocation of ECMO in times of increasing scarcity. [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]

A 44-year-old male with an out-of-hospital cardiac arrest due to an acute left ventricular (LV) inferoposterior wall myocardial infarction (MI) involving the right ventricle (RV) is presented. This case highlights the challenges in the management of patients with cardiac arrest, indications for use of ventricular assist devices, potential effects of LV assist devices on the RV in the setting of RV MI, and culprit versus complete coronary artery revascularization in these patients. [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: Major bleeding has been a common and serious complication with poor outcomes in ECMO patients. With a novel, less-invasive cannulation approach and closer coagulation monitoring regime, the incidence of major bleeding is currently not determined yet. Our study aims to examine the incidence of major bleeding, its determinants, and association with mortality in peripheral-ECMO patients.Method: We conducted a single-center retrospective study on adult patients undergoing peripheral-ECMO between January 2019 and January 2020 at a tertiary referral hospital. Determinants of major bleeding were defined by logistic regression analysis. Risk factors of in-hospital mortality were determined by Cox proportional hazard regression analysis.Results: Major bleeding was reported in 33/105 patients (31.4%) and was associated with higher in-hospital mortality [adjusted hazard ratio (aHR) 3.56, 95% confidence interval (CI) 1.63-7.80, p < 0.001). There were no significant difference in age, sex, ECMO indications, ECMO modality, pre-ECMO APACHE-II and SOFA scores between two groups with and without major bleeding. Only APTT >72 seconds [adjusted odds ratio (aOR) 7.10, 95% CI 2.60-19.50, p < 0.001], fibrinogen <2 g/L [aOR = 7.10, 95% CI 2.60-19.50, p < 0.001], and ACT >220 seconds [aOR = 3.9, 95% CI 1.20-11.80, p=0.017] on days with major bleeding were independent predictors.Conclusions: In summary, major bleeding still had a fairly high incidence and poor outcome in peripheral-ECMO patients. APTT > 72 seconds, fibrinogen < 2 g/L were the strongest predicting factors for major bleeding events. [ABSTRACT FROM AUTHOR]

What is known and objective: Although pulmonary haemorrhage as a complication of ECMO has been well documented, optimal management is not fully elucidated. We describe the role of nebulized tranexamic acid as a therapeutic alternative. Case summary: We report a case series of three patients with ARDS on ECMO complicated by pulmonary haemorrhage. These patients were treated with 500 mg of nebulized tranexamic acid via the endotracheal tube. Key observations included significant stabilization of haemodynamics, reduced circuit changes and less time off of anticoagulation. What is new and conclusion: This series demonstrates successful bleeding management with nebulized tranexamic acid, reducing the frequency of ECMO circuit changes, time off of anticoagulation and blood loss. [ABSTRACT FROM AUTHOR]

We report the cases of two patients experiencing persistent severe hypothermia. They were 45 and 30 years old and had a witnessed cardiac arrest managed with mechanized cardiopulmonary resuscitation (CPR) for 4 and 2.5 hours, respectively. Extracorporeal membrane oxygenation was used in both patients who fully recovered without any neurological sequelae. These two cases illustrate the important role of extracorporeal CPR (eCPR) in persistent severe hypothermia leading to cardiac arrest. [ABSTRACT FROM AUTHOR]

Patients with mitochondrial disease exhibit disrupted pyruvate oxidation, resulting in intraoperative and perioperative physiologic derangements. Increased enzymatic conversion of pyruvate via lactate dehydrogenase during periods of fasting or stress can lead to metabolic decompensation, with rapid development of fatal lactic acidosis. We describe the intraoperative management and postoperative critical care of a patient with mitochondrial disease who presented for repair of esophageal perforation following repair of a paraesophageal hernia. His surgery was complicated by the development of metabolic crisis and severe lactic acidosis which became resistant to conventional therapy before ultimately resolving with the initiation of venoarterial extracorporeal membrane oxygenation (VA-ECMO). [ABSTRACT FROM AUTHOR]

Controlling air leaks during thoracic drainage in patients with lung abscesses caused by bronchopleural fistulas is challenging. To reduce the occurrence of air leaks, positive pressure ventilation should be avoided whenever possible. A 69-year-old man presented with a 10-day history of gradually worsening chest pain. He had lost consciousness and was brought to the emergency room. His SpO2 was approximately 70%, and his systolic blood pressure was approximately 60 mmHg. Chest radiography and computed tomography revealed findings suggestive of a right pyothorax. Therefore, thoracic drainage was performed. However, the patient's respiratory status did not improve, and his circulatory status could not be maintained. Therefore, extracorporeal membrane oxygenation was introduced after the improvement in circulation by noradrenaline and fluid resuscitation, resulting in adequate oxygenation and ventilation without the use of high-pressure ventilator settings. Subsequently, omentoplasty for a refractory bronchopleural fistula was successfully performed, and the air leak was cured without recurrence of the lung abscess. [ABSTRACT FROM AUTHOR]

We report two children with rhabdomyolysis-associated acute kidney injury who were successfully treated with a haemoadsorption column CytoSorb® in addition to continuous renal replacement therapy (CRRT). A 14-year-old girl with multiorgan failure requiring extracorporeal membrane oxygenation developed rhabdomyolysis due to reperfusion injury. Her creatine kinase (CK) and lactate levels continued to escalate despite high-dose CRRT. A haemoadsorption column was therefore added post-CRRT filter, which brought down the CK level from 264,500 IU/L to 97,436 IU/L after 8 hours of therapy. Another 4-year-old boy with epilepsy and cerebral palsy who was admitted for gastroenteritis with dehydration developed acute kidney injury and rhabdomyolysis with a peak CK level of 946,060 IU/L. He was initially treated with CRRT for 40 hours, which reduced his CK level to 147,580 IU/L. Two sessions of haemoadsorption were then performed in addition to the CRRT, which further lowered his CK level to 32,306 IU/L in 48 hours. Both patients demonstrated enhanced reduction of CK levels when the haemoadsorption column was used in addition to the CRRT, and no specific complication related to the haemoadsorption therapy was reported. Our cases showed that haemoadsorption can be considered as an adjunctive therapy for children with severe rhabdomyolysis-associated acute kidney injury. [ABSTRACT FROM AUTHOR]

Aim: To identify, simulate and evaluate the formal and informal patient‐level and unit‐level factors that nurse managers use to determine the number of nurses for each shift. Background: Nurse staffing schedules are commonly set based on metrics such as midnight census that do not account for seasonality or midday turnover, resulting in last‐minute adjustments or inappropriate staffing levels. Methods: Staffing schedules at a paediatric intensive care unit (PICU) were simulated based on nurse‐to‐patient assignment rules from interviews with nursing management. Multivariate regression modelled the discrepancies between scheduled and historical staffing levels and constructed rules to reduce these discrepancies. The primary outcome was the median difference between simulated and historical staffing levels. Results: Nurse‐to‐patient ratios underestimated staffing by a median of 1.5 nurses per shift. Multivariate regression identified patient turnover as the primary factor accounting for this difference and subgroup analysis revealed that patient age and weight were also important. New rules reduced the difference to a median of 0.07 nurses per shift. Conclusion: Measurable, predictable indicators of patient acuity and historical trends may allow for schedules that better match demand. Implications for Nursing Management: Data‐driven methods can quantify what drives unit demand and generate nurse schedules that require fewer last‐minute adjustments. [ABSTRACT FROM AUTHOR]