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Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) flows are titrated to achieve adequate perfusion while attempting to ideally maintain arterial pulse pressure (PP). We assessed risk in patients with low PP defined as <10 mmHg within the first 2 days of support., Methods: Demographics, haemodynamics, echocardiographic and radiological findings were recorded retrospectively in cases conducted between 2014 and 2016. Outcomes were hospital mortality, requirement for renal replacement therapy (RRT) and severe pulmonary oedema (PO)., Results: Of 101 patients, 66.3% were male, mean age was 56 (range 18-71 years), mean duration of support was 6.3 days ± 4.1 days, 37.6% died prior to hospital discharge, 39.6% needed RRT and 11.9% had severe PO. Areas under the receiver operating curves of PP at 48 h for hospital mortality, RRT and severe PO were (respectively): 0.69 (95% CI 0.58-0.80, p = .001), 0.64 (95% CI 0.50-0.77, p = .044), 0.69 (95% CI 0.55-0.82, p = .009). The odds ratio for mortality, RRT, severe PO for those with low PP were (respectively) 2.8 (95% CI 1.01-7.5, p = .04), 3.1 (95% CI 1.11-8.40, p = .026), 7.6 (95% CI 2.06-27.89, p = .001). Central venous pressure, mean arterial pressure were not predictive., Conclusion: PP during the first 2 days of support is predictive of clinically important outcomes in patients supported with VA-ECMO., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aim: We describe the experience of a new paediatric heart transplant (HT) centre in Australia. New South Wales offers quaternary paediatric cardiac services including comprehensive care pre- and post-HT; however, perioperative HT care has previously occurred at the national paediatric centre or in adult centres. Internationally, perioperative HT care is highly protocol-driven and a majority of HT occurs in low volume centres. Establishing a low volume paediatric HT centre in New South Wales offers potential for quality HT care close to home., Methods: Retrospective review of programme data for the first 12 months was undertaken. Patient selection was audited against the programme's intended initiation criteria. Longitudinal patient data on outcomes and complications were obtained from patient medical records., Results: The programme's initial phase offered HT to children with non-congenital heart disease and no requirement for durable mechanical circulatory support. Eight patients met criteria for HT referral. Three underwent interstate transfer to the national paediatric centre. Five children (13-15 years, weight 36-85 kg) underwent HT in the new programme. Individual predicted 90-day mortality was 1.3-11.6%, with increased risk for recipients transplanted from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and with restrictive/hypertrophic cardiomyopathies. Survival at 90 days and for duration of follow-up is 100%. Observed programme benefits include mitigation of family dislocation and improved continuity of care within a family-centred programme., Conclusion: Audit of the first 12 months' activity of a second paediatric HT centre in Australia demonstrates adherence to proposed patient selection criteria and excellent 90-day patient outcomes. The programme demonstrates feasibility of care close to home, providing continuity for all patients including those requiring increased rehabilitation and psychosocial support post-transplantation., (© 2023 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Objectives: We report our experience with temporary postoperative venopulmonary arterial extracorporeal life support as short-term right ventricular support in patients with biventricular failure undergoing HeartWare (HeartWare Inc, Framingham, Mass) left ventricular assist device implantation and compared these outcomes with isolated left ventricular assist device support and long-term biventricular assist device support., Methods: A total of 112 consecutive patients were studied, 75 with the isolated HeartWare left ventricular assist device, 23 with a concomitant left ventricular assist device and venopulmonary arterial extracorporeal life support, and 14 with durable biventricular assist device support. The decision concerning short-term or durable biventricular support was based on the clinical characteristics, echocardiography, and hemodynamic profile., Results: Patients who required venopulmonary arterial extracorporeal life support after left ventricular assist device insertion required the greatest support preoperatively and were more likely to have Interagency Registry for Mechanical Assisted Circulatory Support level 1 (left ventricular assist device 19%, venopulmonary arterial extracorporeal life support 48%, biventricular assist device 57%, P < .001). They were more likely to require preoperative mechanical support (left ventricular assist device 9%, venopulmonary arterial extracorporeal life support 43%, and biventricular assist device 29%, P < .001) or preoperative ventilation (9%, 38%, and 21%, respectively, P < .05). Preoperative echocardiographic and hemodynamic parameters were more similar to those requiring isolated left ventricular assist device, with patients requiring durable biventricular assist device support more likely to have elevated right atrial pressure (left ventricular assist device 14.3 ± 6.7 vs venopulmonary arterial extracorporeal life support 13.6 ± 4.8 vs biventricular assist device 18.7 ± 6.0 mm Hg, P < .05); right atrial/pulmonary capillary wedge pressure ratio (0.53 ± 0.23 vs 0.51 ± 0.17, vs 0.69 ± 0.22, respectively, P < .02); and tricuspid regurgitation grade (1.7 ± 1.5 vs 1.7 ± 1.6 vs 2.8 ± 1.6, respectively, P < .01). One-year survival was 84% for those with an isolated left ventricular assist device compared with 62% for those with venopulmonary arterial extracorporeal life support and 64.3% for biventricular assist device., Conclusions: In critically unwell patients requiring temporary biventricular support, planned venopulmonary arterial extracorporeal life support provides acceptable outcomes, similar to durable biventricular assist device support. Requirement for venopulmonary arterial extracorporeal life support is more determined by the level of preoperative acuity than echocardiographic or hemodynamic parameters., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Objectives: To characterize the longitudinal hemostatic profile during adult ECMO using point-of-care tests (POCT) for coagulation and to compare these parameters to standard laboratory tests. In addition, the clinicians' responses during bleeding episodes using available information were compared to a POCT-based response., Design: Prospective observational cohort study., Setting: ECMO-referral center in a university teaching hospital., Participants: Ten critically ill adult ECMO patients., Interventions: Daily laboratory coagulation profile, transfusion history and near-daily thromboelastometry (ROTEM®) and platelet aggregometry (Multiplate®)., Main Results: Six male and four female patients, seven with VA- and three with VV-ECMO were studied over 110 days. Seventy-five thromboelastometry (TEM) and 36 platelet aggregometry (MEA) results were analyzed. A majority of TEM values were within the normal range, except for FIBTEM (majority high), which remained consistent over long (>5 days) ECMO runs. In MEA there were low values, particularly in the adenosine diphosphate- and ristocetin-induced assay, implying possibly a vWF-factor or GpIb-receptor defect. There was correlation between laboratory and POCT as well as good correlation between the clot firmness after 10 minutes (A10) and the maximum clot firmness in ROTEM, suggesting that reliable information can be obtained within 15 minutes. Twenty-two bleeding episodes were observed in five patients. When comparing the clinicians' response to a transfusion algorithm based on POCT, there was a concordance in less than 20% of episodes., Conclusions: POCT for coagulation can provide specific, reliable, and timely information during bleeding episodes and the use of targeted therapy algorithms could improve outcomes and reduce costs., (Crown Copyright © 2015. Published by Elsevier Inc. All rights reserved.)

Background: Owing to persisting donor shortages, the use of "marginal hearts" has increased. Because patients who receive a marginal heart may require hemodynamic support in the early post-operative period, extracorporeal membrane oxygenation (ECMO) may be used until recovery of acute graft dysfunction., Methods: A retrospective file review of 124 primary adult heart transplant patients from 2003 to 2008 was conducted. We compared 17 patients who received post-transplant ECMO support with 107 transplant recipients without ECMO. Donor and recipient pre-transplant, intra-operative, and post-transplant clinical variables to 6 months after transplant were compared., Results: Pre-operative demographics of the 2 groups were similar. Eight (47%) of the patients in the ECMO group received marginal donor hearts, compared with 1 (1%) in the non-ECMO group (p < 0.05). There were 3 early deaths in the ECMO group (2 of whom had received optimal donor hearts), resulting in lower Day 30 ECMO survival of 82.4% vs 100% for non-ECMO, respectively (p < 0.001), and 6-month survival of 82.4% vs 95.6%, respectively (p < 0.02). Most of the difference in survival was in patients who required salvage ECMO despite normal pre-transplant donor LV function. The rate of early dialysis was higher in the ECMO group, at 18% vs 6% at Day 3, but there was no difference between the 2 groups by Day 7. Pre-discharge ventricular function was normal in all discharged ECMO patients and all but 1 non-ECMO patient. ECMO patients had a longer intensive care unit stay (8.9 ± 3.4 vs 4.8 ± 5.4 days, p < 0.005), but there was a slightly shorter ward stay, resulting in a similar overall hospitalization length of stay (22.9 ± 8.3 vs 25.1 ± 25.2 days)., Conclusions: ECMO allows for salvage of acute graft dysfunction and may allow use of marginal donor hearts. Survival rates are lower in patients who require ECMO compared with optimal donors, but early cardiac dysfunction normalizes in most without long-term cardiac or renal sequelae. Despite longer ventilation times, overall hospitalization is not prolonged., (Crown Copyright © 2011. Published by Elsevier Inc. All rights reserved.)

A 53-year-old man presented to the ED with refractory ventricular fibrillation secondary to an occluded proximal left anterior descending coronary artery. We report the first case of extracorporeal membrane oxygenation instituted in our ED. It is one of the few reports in the literature of extracorporeal membrane oxygenation being utilized in the ED as a resuscitation measure.

Heart transplantation is the gold standard treatment for end-stage heart failure. However, the number of available organs is numerically inadequate to address this problem. One potential way to overcome the organ shortage is to broaden criteria for acceptable donations to include a sub-pool of marginal donors. This study aims to assess our outcomes for patients receiving marginal cardiac transplants compared to their counterparts. The analysis is particularly important as our centre has recently begun to utilise the XVIVO hypothermic perfusion machine for organ storage, challenging accepted definitions of organ marginality based on ischaemic time. We conducted a single-centre retrospective cohort study to identify all heart transplant recipients from 2010-2021. Patients who received a combined heart-lung transplant were excluded, as were organs obtained through the donation after circulatory death (DCD) pathway. We identified all marginal donors meeting any of the accepted criteria; donor age >60 years, donor LVEF <55%, use of T3 in the donor, or donor ischemic time >6hrs or >4hrs if donor age >40 years. 371 patients met our inclusion criteria for this study. Based on accepted criteria, 120 (32%) of donors were identified as marginal. Of these 120 marginal donors, 64 (53%) met the prolonged ischaemic time criteria. Overall mean donor age was 37.2 years +/- 12.6 and mean donor ischaemic time was 225 minutes +/- 67 minutes. Utilisation of extra-corporeal membrane oxygenation (ECMO) was higher in the marginal donor group (33 patients, 28%) compared to the non-marginal group (35 patients, 14%), p=0.002. There was no difference in new renal failure, requirement for dialysis or post-operative length of stay. 14 patients (6%) in the non-marginal group died within 30-days of their transplant, compared to 5 patients (4%) in the marginal group, p=0.56). Our centre's experience indicates that carefully selected marginal donors demonstrate similar short term post-transplant outcomes when compared to their non-marginal counterparts. Furthermore, our utilisation of the XVIVO hypothermic perfusion organ storage device is likely to further challenge the accepted definition of marginal cardiac donors by allowing for longer periods of donor ischaemic time and may improve post-operative ECMO rates in the marginal donor group. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy providing hemodynamic support to patients with advanced cardiorespiratory compromise. Following orthotopic heart transplantation (HTX), primary graft failure (PGF), especially wherein there is significant right ventricular dysfunction, can necessitate such intensive support to bridge to recovery or additional therapy. Marginal donors are used to increase the donor pool given the excess of candidates in most jurisdictions. We conducted a single-center retrospective cohort study examining HTX from donation after brain death (DBD) donors that required post-operative ECMO for PGF from January 2008 - September 2020. Donor and recipient information were collected including demographics, renal function, echocardiographic measurements, biopsy data, and outcome measures. Marginal donor hearts were identified according to validated criteria including use of donor triiodothyronine (T3), donor left ventricular ejection fraction <55%, donor age >60 years old, and donor ischemic time >6 hours or >4 hours if donor age >40 years old. Overall, 376 DBD HTX were performed, of which 126 involved marginal donor hearts (33.3%). ECMO was required in 81 (21.4%) of these patients, 42 (51.9%) of which involved marginal donor hearts. Thus, ECMO rates were 15.5% and 33.3% in non-marginal and marginal donor hearts, respectively. Overall, ECMO was successfully weaned in 75 (92.6%) and 62 (76.5%) survived their index HTX admission. Among patients who received non-marginal organs, 36 (92.3%) had ECMO weaned and 31 (79.5%) survived their index HTX admission versus 39 (92.9%) and 31 (73.8%) for these endpoints respectively among patients receiving marginal organs. Our center's experience indicates that ECMO can provide satisfactory outcomes in HTX patients requiring advanced hemodynamic support post-operatively for PGF. Marginal donor hearts were more likely to require ECMO support post-operatively but had comparable and acceptable rates of index-admission survival compared to non-marginal cases. Further work is needed to evaluate outcome differences as efforts are made to expand the donor pool around the world. [ABSTRACT FROM AUTHOR]