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Background: Extracorporeal membrane oxygenation (ECMO) has gained traction as a bridge to heart transplantation (HT) but remains associated with increased waitlist mortality. This study explores whether this risk is modified by underlying heart failure (HF) etiology., Methods: Using the Organ Procurement and Transplantation Network registry, we conducted a retrospective review of first-time adult HT candidates from 2018 through 2022. Patients were categorized as "ECMO", if ECMO was utilized during the waitlisting period, or "No ECMO" otherwise. Patients were then stratified according to the following HF etiology: ischemic cardiomyopathy (CMP), dilated nonischemic CMP, restrictive CMP, hypertrophic CMP, and congenital heart disease (CHD). After baseline comparisons, waitlist mortality was characterized for ECMO and HF etiology using the Fine-Gray regression., Results: A total of 16 143 patients were identified of whom 7.0% (n = 1063) were bridged with ECMO. Compared to No ECMO patients, ECMO patients had shorter waitlist durations (46.3 vs. 185.0 days, p < 0.01) and were more likely to undergo transplantation (75.3% vs. 70.3%, p < 0.01). Outcomes analysis revealed that ECMO was associated with increased mortality risk (subdistribution hazard ratio [SHR]: 3.42, p < 0.01), a risk that persisted in all subgroups and was notably high in CHD (SHR: 4.83, p < 0.01) and hypertrophic CMP (SHR: 9.78, p < 0.01). HF etiology comparison within ECMO patients revealed increased mortality risk with CHD (SHR: 3.22, p < 0.01). Within No ECMO patients, hypertrophic CMP patients had lower mortality risk (SHR: 0.64, p = 0.03)., Conclusions: The increased waitlist mortality risk with ECMO persisted after stratification by HF etiology. These findings can help decision-making surrounding candidacy for cannulation and prognostic evaluation., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: With the implementation of the new heart allocation system, heart transplantation teams are prompted to reevaluate management of patients requiring mechanical circulatory support. The purpose of our study is to compare the outcomes of patients supported with extracorporeal membrane oxygenation (ECMO) before transplantation., Methods: The United Network for Organ Sharing database was queried for all adult patients (aged 18 years or more) who required support with ECMO before heart transplantation from 2001 to 2018. Patients were stratified into patients who did not require ECMO before transplantation, who were weaned off ECMO before transplantation, who were bridged immediately to transplantation from ECMO, and who were bridged to a left ventricular assist device (LVAD) before transplantation. Demographics and outcomes including 1-year survival, postoperative stroke, postoperative renal failure requiring dialysis, episodes of rejection, and graft failure were compared., Results: Overall, 29,370 patients did not require ECMO before transplantation, 101 patients were weaned off ECMO before transplantation, 118 were bridged from ECMO directly to transplantation, and 55 patients were successfully bridged from ECMO to LVAD before transplantation. Kaplan-Meier survival estimates found a statistically significant decrease in 1-year survival for patients who were bridged from ECMO to transplantation compared with patients who were bridged to LVAD before subsequent transplantation (P < .001)., Conclusions: Our study suggests bridging ECMO patients to an LVAD before transplantation will result in improved 1-year survival compared with patients bridged to immediate transplantation. With the new heart allocation system, continued evaluation of outcomes is required to inform management strategies., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Although acute brain injury is common in patients receiving extracorporeal membrane oxygenation, little is known regarding the mechanism and predictors of ischemic and hemorrhagic stroke. We aimed to determine the risk factors and outcomes of each ischemic and hemorrhagic stroke in patients with venoarterial extracorporeal membrane oxygenation support., Design: Retrospective analysis., Setting: Data reported to the Extracorporeal Life Support Organization by 310 extracorporeal membrane oxygenation centers from 2013 to 2017., Patients: Patients more than 18 years old supported with a single run of venoarterial extracorporeal membrane oxygenation., Interventions: None., Measurements and Main Results: Of 10,342 venoarterial extracorporeal membrane oxygenation patients, 401 (3.9%) experienced ischemic stroke and 229 (2.2%) experienced hemorrhagic stroke. Reported acute brain injury during venoarterial extracorporeal membrane oxygenation decreased from 10% to 6% in 5 years. Overall in-hospital mortality was 56%, but rates were higher when ischemic stroke and hemorrhagic stroke were present (76% and 86%, respectively). In multivariable analysis, lower pre-extracorporeal membrane oxygenation pH (adjusted odds ratio, 0.21; 95% CI, 0.09-0.49; p < 0.001), higher PO2 on first day of extracorporeal membrane oxygenation (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.009), higher rates of extracorporeal membrane oxygenation circuit mechanical failure (adjusted odds ratio, 1.33; 95% CI, 1.02-1.74; p = 0.03), and renal replacement therapy (adjusted odds ratio, 1.49; 95% CI, 1.14-1.94; p = 0.004) were independently associated with ischemic stroke. Female sex (adjusted odds ratio, 1.61; 95% CI, 1.16-2.22; p = 0.004), extracorporeal membrane oxygenation duration (adjusted odds ratio, 1.01; 95% CI, 1.00-1.03; p = 0.02), renal replacement therapy (adjusted odds ratio, 1.81; 95% CI, 1.30-2.52; p < 0.001), and hemolysis (adjusted odds ratio, 1.87; 95% CI, 1.11-3.16; p = 0.02) were independently associated with hemorrhagic stroke., Conclusions: Despite a decrease in the prevalence of acute brain injury in recent years, mortality rates remain high when ischemic and hemorrhagic strokes are present. Future research is necessary on understanding the timing of associated risk factors to promote prevention and management strategy.

We report a case of intracranial hypertension presenting with bradycardia as the only component of Cushing's triad in a patient on extracorporeal membrane oxygenation. A 41-year-old woman with recurrent driveline infections of HeartMate-II had sternotomy and debridement that was complicated by right ventricular failure requiring veno-arterial extracorporeal membrane oxygenation. Patient was comatose and acute onset of bradycardia occurred without any change in blood pressure or respiration. Computed tomography of brain demonstrated an uncal herniation from diffuse cerebral edema. Acute onset of bradycardia in comatose patients may be the sole component of Cushing's triad in laminar flow circulatory support.

This article reviews the surgical considerations of cardiac allograft rejection after heart transplantation and describes current treatment modalities for the failing graft. Cardiac allograft rejection can be a moribund diagnosis, especially when it is acute and high grade. It is broadly categorized into hyperacute, acute cellular, and antibody-mediated rejection. Treatment includes a multitude of medical and immunomodulation therapies for graft recovery. Severe rejection requires mechanical circulatory support for hemodynamic stability to maintain end-organ function. Retransplantation for graft loss is the ultimate therapy; however, it portends poor outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Severe right ventricular (RV) failure is a significant cause of morbidity and mortality, with an in-hospital mortality rate up to 70% to 75%. Medical management is employed and is successful for most of these patients. However, a small percentage of patients will continue to have persistent RV failure, for which mechanical support is used for management., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Despite limited organ availability, extracorporeal membrane oxygenation (ECMO) and retransplantation are becoming more commonplace., Methods: Using the United Network for Organ Sharing (UNOS) database, we evaluated survival of patients treated with ECMO before lung transplantation and undergoing retransplantation. A query identified cadaveric recipients from 2001 to 2012 over the age of 6 years., Results: Of 15,772 lung recipients, 15 583 never received ECMO, whereas 189 did. Mean age was 52.1 ± 14.4 versus 46.8 ± 16.5 years for non-ECMO and ECMO groups, respectively (p < 0.0001). Using Kaplan-Meier method, there were survival differences between ECMO and non-ECMO groups (p < 0.0001) and first-time transplants with and without ECMO to retransplants with and without ECMO (p < 0.0001). The proportional hazards model identified higher risk with ECMO use in idiopathic pulmonary fibrosis (hazard ratio [HR] 1.09; 95 % confidence interval (CI), 1.02-1.17; p = 0.014) and retransplants (HR 1.77; 95 % CI, 1.55-2.03; p < 0.0001)., Conclusions: Survival for retransplantation was similar to ECMO as a primary option with significant mortality associated with ECMO use in patients with idiopathic pulmonary fibrosis and retransplants.

Stroke is a well‐characterized complication of isolated heart and lung transplantation, but has not been described in combined heart‐lung transplantation (HLTx). We retrospectively reviewed national U.S. data to describe the incidence, risk factors, and impact of postoperative stroke in HLTx recipients. Of 871 heart‐lung recipients between 1994–2022, 35 (4.0%) experienced stroke, and the incidence increased over time, trending toward significance (p‐trend =.07). After adjustment, extracorporeal membrane oxygenation (ECMO) (Adjusted odds ratio [aOR] = 2.63, 95%CI = [1.13–6.11]) and pre‐transplant implantable defibrillator (aOR = 2.86, 95%CI = [1.20–6.81]) were independent risk factors for stroke. Postoperative stroke is common and is increasing in an era where organ allocation is driven by mechanical circulatory support (MCS) bridging. [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]

Ventricular septal rupture (VSR) is a rare complication of myocardial infarction that requires surgical repair. Herein, we describe a case of intraoperative VSR requiring patch repair and postoperative extracorporeal membrane oxygenation (ECMO) support. This case highlights the risk factors, patient presentation, and management recommendations for this potentially lethal pathology. [ABSTRACT FROM AUTHOR]

We investigated how the 2018 Organ Procurement and Transplantation Network heart allocation policy change was associated with changes in characteristics and outcomes of candidates receiving multiple temporary mechanical circulatory support (mtMCS) devices. We included adult heart transplant candidates listed October 2014-January 2018 and October 2018-January 2022 in the United Network of Organ Sharing dataset. Prepolicy and postpolicy mtMCS recipients were compared at listing, transplant, 90-days, and 1-year post-transplant. Time between first and second devices and time between first device and transplant were modeled via multivariable linear regression. Transplantation likelihood was modeled using competing risks analysis. Postpolicy, a higher proportion of transplant candidates received mtMCS (4% versus 1%, P < 0.001), and received their second device an adjusted 49 d sooner versus prepolicy (P = 0.001). Time to transplant was also an adjusted 35 d shorter postpolicy, with an 80% increased transplantation likelihood versus prepolicy (95% confidence interval: 1.6-1.9, P < 0.001). Postpolicy patients experienced reduced waitlist mortality (8% versus 14%, P = 0.04) with marked improvements in 90-day (93% versus 85%, P < 0.001) and 1-year (88% versus 70%, P = 0.01) post-transplant survival. Postpolicy mtMCS recipients are more likely to progress to transplantation sooner on the waitlist and their shorter waitlist course together with earlier change to a secondary device was associated with improved post-transplant survival versus prepolicy. [ABSTRACT FROM AUTHOR]