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Postcardiotomy extracorporeal membrane oxygenation (PC-ECMO), the most frequent indication for ECMO in the United States, is increasingly used as the first-line mechanical circulatory support in patients who are refractory to conventional treatment. Despite increasing use of PC-ECMO, limited evidence is available regarding its safety, efficacy, and optimal timing for initiation and weaning. The decision to use PC-ECMO often is made in the absence of robust clinical data, leading to variability in patient selection, management, and outcomes across different institutions. This article summarizes current evidence on ECMO use in postcardiotomy cardiogenic shock and discusses its potential benefits, management, complications, and outcomes. [ABSTRACT FROM AUTHOR]

Pump exchange is an established strategy to treat LVAD related complications such as thrombosis, infection and driveline failure, even in the setting repeated procedures. Pump upgrades with an exchange to newer generation devices are being performed to the advantage of patient on long term support. Safety and efficacy of a repeat LVAD exchange with concomitant upgrade to a third generation pump has not been reported We performed a retrospective analysis of all consecutive patients who underwent a repeat LVAD device exchange and upgrade to HeartMate III (HMIII) at Houston Methodist Hospital between December 2018 and December 2020. Five patient underwent a repeat exchange and upgrade to HMIII within the specified timeframe. Four patients had already had 2 prior exchanges (all HMII to HMII), one patient had 1 prior exchange (HVAD to HVAD). In all cases, implantation was performed as a destination therapy. Surgical exchange was performed via re-do median sternotomy on full cardiopulmonary bypass. No unplanned redo surgery or repositioning of the device component was required. In hospital mortality was 20% in this very high risk population. At 1, 3 and 6 months follow up, all discharged patients were on HMIII support, with no major LVAD related adverse events reported (infection, pump thrombosis, driveline failure). We report the feasibility and safety of a repeat pump exchange with upgrade to HMIII in a large volume center. The decision for medical therapy versus surgical exchange has to be tailored to individual cases based on risk factors and clinical stability but in expert hands, even a re-redo surgical approach with upgrade appears to be feasible and granting options for good medium term outcomes. [ABSTRACT FROM AUTHOR]

Background Limited data exist on factors predicting prolonged survival in left ventricular assist device (LVAD) recipients. We sought to identify patient characteristics and complications associated with prolonged survival. Methods We conducted retrospective review of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database, including primary continuous-flow LVAD recipients, between May 2012 and March 2013. Patients were identified as having survived with a device in place after 3 years or not, conditional on having initially survived 6 months. Patients who received a transplant, underwent explant due to recovery, or were lost to follow-up before 3 years were excluded. Multivariate logistic regression evaluated perioperative factors and adverse events within 6 months associated with long survival. Results Of 1,116 patients who survived past the initial 6 months, 725 (65%) survived beyond 3 years. On univariate analysis, long-term survivors were significantly younger, were less likely to be white, supported for destination therapy, have diabetes, solid-organ cancer, or take amiodarone. On multivariate analysis, factors associated with increased odds of death at 3 years included diabetes, amiodarone use, and developing stroke, gastrointestinal bleeding, hemolysis, or pump thrombosis within 6 months of implantation. Conclusions Preoperative diabetes and amiodarone use were associated with poor long-term survival in LVAD recipients. Development of early complications of stroke, gastrointestinal bleeding, hemolysis, or pump thrombosis was also associated with poor long-term survival. Early diagnosis and treatment of these complications may improve survival in LVAD recipients. [ABSTRACT FROM AUTHOR]

Bleeding and hemocompatibility-related adverse events (HRAEs - bleeding, neurological event, stroke, arterial thrombosis, pump thrombosis, and death) remain significant in LVAD patients; changes in coagulation homeostasis, mainly due to von Willebrand Factor (vWF) structural and functional changes induced by mechanical support have been considered a major player in these adverse events. However, the specific mechanisms and the clinical correlation between coagulation profile parameters and clinical outcomes are not yet completely clarified. We hypothesized that coagulation profile parameters analyzing vWF functionality would be associated with bleeding events and HRAE. We prospectively studied patients on LVAD support at our Institution from 2019 to 2021; blood samples were collected, and an in-depth pilot analysis of their coagulation profile was assessed with vWF assays, coagulation factor assays, platelet function analysis, and routine laboratory tests. Baseline information of all patients including demographic characteristics and clinical outcomes along with the time on support were collected from electronic medical records. The primary endpoint in our analysis was any bleeding. The secondary endpoint was a composite of all HRAEs. The discriminatory power of predictors for outcomes was determined by the area under the ROC curve (AUC). Of the 53 LVAD patients studied (13=HVAD, 40=HMIII), 24 (45.3%) experienced bleeding events; and 34 (64.2%) met the criteria for our secondary composite outcomes. vWF multimer assays were not associated with bleeding or HRAE. No significant differences were evident in clinical characteristics, time on support, or type of LVAD, between patients who experienced bleeding or HRAEs. Among coagulation profile parameters, patients with bleeding events had a higher measured vWF Collagen Binding Activity (vWF:CB) [183.0 (164.0, 218.0) vs 137.0 (106.0, 175.0) IU/dl, p=0.01] while patients with HRAE had higher levels of vWF propeptide [193.0 (167.0, 241.0) vs 149.5 (115.0, 175.0) IU/dl, p= 0.045]. vWF:CB and vWF propeptide had good performances in predicting bleeding and HRAEs complications, respectively (Figure 1). In this pilot study, our findings suggest that vWF activation rather than cleavage predict bleeding events and HRAEs. Coagulation profile measurements on LVAD patients may provide insight into bleeding risks and HRAEs thus translating into personalized care and outcome improvement. [ABSTRACT FROM AUTHOR]