Acute Decompensated Heart Failure Secondary to Left Atrial Myxoma: A Case Report Highlighting Diagnostic Challenges and Multidisciplinary Management.

Cardiac myxomas are the most common benign tumors of the heart, with clinical manifestations varying significantly based on tumor size. Symptoms can range from asymptomatic and mild non-specific presentations to severe obstructive cardiac and systemic findings. This case report describes a 68-year-old female patient who presented with acute decompensated heart failure. Diagnostic evaluation revealed a left atrial myxoma causing significant mitral valve obstruction. The patient underwent emergency cardiac surgery for tumor removal, complicated by severe mitral and tricuspid valve regurgitation. Following valve replacement and repair, the patient required extracorporeal life support. Despite these complexities, she achieved significant recovery and was discharged in good condition. At follow-up, she remained asymptomatic with no signs of cardiac decompensation. This case highlights the importance of considering cardiac myxoma as a differential diagnosis in such cases to prevent potential complications.

A training programme for novice extracorporeal resuscitation providers.

Introduction: The use of extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest is increasing globally. However, providing equity of access to all patients is challenging, and to date, access has been limited to inner city areas surrounding major hospitals. To increase the availability of ECPR in our jurisdiction, we sought to train pre-hospital physicians with no experience in extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR). To enable this, we sort to develop and teach a syllabus that would provide novice ECPR providers the skill to perform ECPR safely and effectively in the pre-hospital environment. Methods: This training programme consisted of 11 pre-hospital physicians and six critical care paramedics. All participants had no prior hospital experience instituting or managing ECPR patients. The training programme was multimodal utilising a porcine model of heart failure to teach time pressured dynamic physiological troubleshooting, cadaver labs to teach cannulation, didactic teaching and simulation. Key knowledge and skill domains were identified. Each learning framework was built upon with a final focus on integrating all skill domains required to successfully initiate ECPR. Results: The training program was completed from February 2022 to August 2023. Knowledge progression was assessed at key stages via written and practical examination. Each participant demonstrated clear knowledge and skill progression at the key stages of the training programme. At the end of the training programme, participants met the pre-defined standards to progress to ECPR provision in the pre-hospital environment. Conclusion: We present a training program for novice ECPR providers performing ECPR in the pre-hospital setting. The outcomes of this training program can provide a training framework for both novices, low volume ECMO centres and pre-hospital clinicians.

Surgical approaches to congenital diaphragmatic hernia.

Surgical repair of the diaphragm is essential for survival in congenital diaphragmatic hernia (CDH). There are many considerations surrounding the operation - why the operation matters, optimal timing of repair and its relation to extracorporeal life support (ECLS) use, minimally invasive versus open approaches, and strategies for reconstruction. Surgery is both affected by, and affects, the physiology of these infants and is an important factor in determining long-term outcomes. Here we discuss the evidence and provide insight surrounding this complex decision making, technical pearls, and outcomes in repair of CDH.

Left Ventricular Unloading in Extracorporeal Membrane Oxygenation: A Clinical Perspective Derived from Basic Cardiovascular Physiology.

PURPOSE OF REVIEW: To present an abridged overview of the literature and pathophysiological background of adjunct interventional left ventricular unloading strategies during veno-arterial extracorporeal membrane oxygenation (V-A ECMO). From a clinical perspective, the mechanistic complexity of such combined mechanical circulatory support often requires in-depth physiological reasoning at the bedside, which remains a cornerstone of daily practice for optimal patient-specific V-A ECMO care. RECENT FINDINGS: Recent conventional clinical trials have not convincingly shown the superiority of V-A ECMO in acute myocardial infarction complicated by cardiogenic shock as compared with medical therapy alone. Though, it has repeatedly been reported that the addition of interventional left ventricular unloading to V-A ECMO may improve clinical outcome. Novel approaches such as registry-based adaptive platform trials and computational physiological modeling are now introduced to inform clinicians by aiming to better account for patient-specific variation and complexity inherent to V-A ECMO and have raised a widespread interest. To provide modern high-quality V-A ECMO care, it remains essential to understand the patient's pathophysiology and the intricate interaction of an individual patient with extracorporeal circulatory support devices. Innovative clinical trial design and computational modeling approaches carry great potential towards advanced clinical decision support in ECMO and related critical care.

Veno-venous extra-corporeal membrane oxygenation in complex tracheobronchial resection.

Background: Elective extra-corporeal membrane oxygenation (ECMO) is rarely used in thoracic surgery, apart from lung transplantation. The purpose of this study was to summarize our institutional experience with the intraoperative use of veno-venous (VV) ECMO in selected cases of main airway surgery. Methods: We retrospectively analyzed the data of 10 patients who underwent main airway surgery with the support of VV-ECMO between June 2013 and August 2022. Results: Surgical procedures included: three carinal resection and reconstruction with complete preservation of the lung parenchyma, one right upper double-sleeve lobectomy and hemi-carinal resection, and one sleeve resection of the left main bronchus after previous right lower bilobectomy, for thoracic malignancies; four tracheal/carinal repair for extensive traumatic laceration; one extended tracheal resection due to post-tracheostomy stenosis in a patient who had previously undergone a left pneumonectomy. The median intraoperative VV-ECMO use was 162.5 minutes. In three cases with complex resection and reconstruction of the carina and in one case of extended post-tracheostomy stenosis and previous pneumonectomy, high-flow VV-ECMO allowed interruption of ventilation for almost 3 hours. In four patients, VV-ECMO was prolonged in the postoperative period to ensure early extubation. There were no perioperative deaths, no complications related to the use of ECMO and no intraoperative change in the planned type of ECMO. Significant complications occurred only in one patient who developed a small anastomotic dehiscence that led to stenosis and required placement of a Montgomery tube. At the median follow-up of 30 months, all 10 patients were still alive. Conclusions: The use of intraoperative VV-ECMO allows safe and precise performance of main airway surgery with minimal postoperative morbidity in patients requiring complex resections and reconstructions and in cases that cannot be managed with conventional ventilation techniques.

Complications related to extracorporeal life support in lung transplantation: single-center analysis.

Background: Extracorporeal life support (ECLS) is not routinely used at our center during sequential single-lung transplantation (LTx), but is restricted to anticipate and overcome hemodynamic and respiratory problems occurring peri-operatively. In this retrospective descriptive cohort study, we aim to describe our single-center experience with ECLS in LTx, analyzing ECLS-related complications. Methods: All transplantations with peri-operative ECLS use [2010-2020] were retrospectively analyzed. Multi-organ and heart-lung transplantation were excluded. Demographics, support type and indications are described. Complications are categorized according to the underlying nature and type. Data are presented as median [interquartile range (IQR)]. Kaplan-Meier was used for survival analysis. Results: The overall use of ECLS was 22% (156/703 patients) with a mean age of 52 years (IQR, 36-59 years). Transplant indications in ECLS cohort were interstitial lung disease (38%; n=60), chronic obstructive pulmonary disease (COPD) (19%; n=29), cystic fibrosis (17%; n=26) and others (26%; n=41). Per indication, 94% (15/16) of pulmonary arterial hypertension patients required ECLS, whereas only 8% (29/382) of COPD patients did. In 16% (25/156) of supported patients, veno-venous extracorporeal membrane oxygenation was initiated, while 77% (120/156) required veno-arterial support, and 7% (11/156) cardiopulmonary bypass. Thirty-day mortality was 6% (9/156). Sixteen percent (25/156) of patients were bridged to transplantation on ECLS and 24% (37/156) required post-operative support. Main reasons to use ECLS were intra-operative hemodynamic instability (53%; n=82), ventilation/oxygenation problems (22%; n=34) and reperfusion edema (17%; n=26). Overall incidence of patients with at least one ECLS-related complication was 67% (n=104). Most common complications were hemothorax (25%; n=39), need for continuous renal replacement therapy (19%; n=30), and thromboembolism (14%; n=22). Conclusions: ECLS was required in 22% of LTxs, with a reported ECLS-related complication rate of 67%, of which the most common was hemothorax. Larger databases are needed to further analyze complications and develop tailored deployment strategies for ECLS-use in LTx.

Off-pump lung re-transplantation avoiding clamshell thoracotomy is feasible and safe: a single-center experience.

Background: Lung re-transplantation (re-LTx) is the only therapeutic option for selected patients with advanced allograft dysfunction. This study aims to describe our center's experience to illustrate the feasibility and safety of off-pump re-LTx avoiding clamshell incision. Methods: We performed a retrospective analysis of 42 patients who underwent bilateral re-LTx between 2007 and 2021. Patients were classified according to their surgical approach and extracorporeal life support (ECLS)-use. Demographics, surgical technique, and short- and long-term outcomes were compared between groups. Continuous data were examined with an independent-sample t-test or non-parametric test. Pearson's chi-squared and Fisher's exact were used to analyze categorical data. Results: Twenty-six patients (61.9%) underwent re-LTx by anterior thoracotomy without ECLS. Compared to the more invasive approach (thoracotomy with ECLS and clamshell with/without ECLS, n=16, 38.1%), clamshell-avoiding off-pump re-LTx patients had a shorter operative time (471.6±111.2 vs. 704.0±273.4 min, P=0.010) and less frequent grade 3 primary graft dysfunction (PGD-3) at 72 h (7.7% vs. 37.5%, P=0.038). No significant difference was found in PGD-3 incidence within 72 h, mechanical ventilation, intensive care unit (ICU) and hospital stay, and the incidence of reoperation within 90 days between groups (P>0.05). In the long-term, the clamshell-avoiding and off-pump approach resulted in similar 1- and 5-year patient survival vs. the more invasive approach. Conclusions: Our experience shows that clamshell-avoiding off-pump re-LTx is feasible and safe in selected patients on a case-by-case evaluation.

Extracorporeal life support in congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is the most common indication for ECLS in neonatal respiratory failure. The ultimate purpose of ECLS is to grant cardiopulmonary support, allowing time for operative intervention and optimization of cardiopulmonary function as the pathophysiologic processes of pulmonary hypertension, pulmonary hypoplasia, and ventricular dysfunction either improve or resolve. In CDH, ECLS plays a crucial role in the management of the most challenging patients, facilitating postnatal stabilization, allowing a ventilation strategy which minimizes barotrauma and volutrauma, and permitting treatment of and recovery from pulmonary hypertension and/or cardiac dysfunction. Understanding the nuances of CDH patients, which differ from other forms of neonatal respiratory failure, and the benefits of ECLS for these infants, is crucial for effective management. CDH patients present distinct challenges. Every aspect of ECLS, from mode of support and anticoagulation medication to pump selection, ventilation strategy, pulmonary hypertension management, and the weaning process, requires meticulous consideration. ECLS for CDH serves as a bridge to making informed decisions, granting clinicians stability and time to manage / recover from specific pathophysiologic consequences, and it offers the potential for survival among even the most challenging and complex patients. As overall care and management for infants with CDH receiving ECLS continue to improve, the focus has shifted toward managing survivor morbidity. Given the multisystem nature of the disease, this requires significant experience, expertise, and multidisciplinary teamwork to optimize long-term outcomes for these patients.

Acute coronary syndrome associated cardiogenic shock in the catheterization laboratory: peripheral veno-arterial extracorporeal membrane oxygenator management and recommendations.

Cardiogenic shock (CS) in acute coronary syndrome (ACS) is a critical disease with high mortality rates requiring complex treatment to maximize patient survival chances. Emergent coronary revascularization along with circulatory support are keys to saving lives. Mechanical circulatory support may be instigated in severe, yet still reversible instances. Of these, the peripheral veno-arterial extracorporeal membrane oxygenator (pVA-ECMO) is the most widely used system for both circulatory and respiratory support. The aim of our work is to provide a review of our current understanding of the pVA-ECMO when used in the catheterization laboratory in a CS ACS setting. We detail the workings of a Shock Team: pVA-ECMO specifics, circumstances, and timing of implantations and discuss possible complications. We place emphasis on how to select the appropriate patients for potential pVA-ECMO support and what characteristics and parameters need to be assessed. A detailed, stepwise implantation algorithm indicating crucial steps is also featured for practitioners in the catheter laboratory. To provide an overall aspect of pVA-ECMO use in CS ACS we further gave pointers including relevant human resource, infrastructure, and consumables management to build an effective Shock Team to treat CS ACS via the pVA-ECMO method.

Extracorporeal life support as a bridge to lung transplantation: a narrative review.

Background and Objective: The utilization of extracorporeal life support (ECLS) as a bridge to lung transplantation (LTx) has rapidly expanded over recent years in highly urgent patients even though the reported outcomes in current literature are still divergent. The aim of our narrative review was to provide a comprehensive picture on the peri and post-operative outcomes of patients bridged to LTx with this device from the most updated literature in the field. Methods: The literature about ECLS bridge to LTx was searched on PubMed using a formal strategy. We focused our research on studies published between 2015 and 2022 and in English language. Abstracts, case reports, conference presentations, editorials, expert opinions and review articles were excluded. Key Content and Findings: ECLS has emerged as a valid tool to bridge critically ill patients to LTx. Some issues, like the selection of candidates and the post-operative outcomes, are still matter of debate in the current reported series. We analyzed 14 papers published in the last seven years and with at least 20 patients to provide an updated overview on this topic. We found that, in highly experienced centers, ECLS can be used as a good strategy to allow critically ill patients to remain eligible to LTx with satisfying post-operative outcomes. Conclusions: Specific scores and algorithms should be implemented to improve the selection process of candidates who could benefit more from ECLS as a bridge to LTx. Ambulatory/awake ECLS strategies should be always preferred to enroll patients in active rehabilitation programs awaiting LTx, improving short and long-term outcomes and increasing the success of LTx.

Expert consensus on training and accreditation for extracorporeal cardiopulmonary resuscitation an international, multidisciplinary modified Delphi Study.

BACKGROUND: A multidisciplinary group of stakeholders were used to identify: (1) the core competencies of a training program required to perform in-hospital ECPR initiation (2) additional competencies required to perform pre-hospital ECPR initiation and; (3) the optimal training method and maintenance protocol for delivering an ECPR program. METHODS: A modified Delphi process was undertaken utilising two web based survey rounds and one virtual meeting. Experts rated the importance of different aspects of ECPR training, competency and governance on a 9-point Likert scale. A diverse, representative group was targeted. Consensus was achieved when greater than 70% respondents rated a domain as critical (> or = 7 on the 9 point Likert scale). RESULTS: 35 international ECPR experts from 9 countries formed the expert panel, with a median number of 14 years of ECMO practice (interquartile range 11-38). Participant response rates were 97% (survey round one), 63% (virtual meeting) and 100% (survey round two). After the second round of the survey, 47 consensus statements were formed outlining a core set of competencies required for ECPR provision. We identified key elements required to safely train and perform ECPR including skill pre-requisites, surrogate skill identification, the importance of competency-based assessment over volume of practice and competency requirements for successful ECPR practice and skill maintenance. CONCLUSIONS: We present a series of core competencies, training requirements and ongoing governance protocols to guide safe ECPR implementation. These findings can be used to develop training syllabus and guide minimum standards for competency as the growth of ECPR practitioners continues.

Quantitative Analysis of Clot Deposition on Extracorporeal Life Support Membrane Oxygenators Using Digital and Scanning Electron Microscopy Imaging Techniques.

Device-induced thrombosis remains a major complication of extracorporeal life support (ECLS). To more thoroughly understand how blood components interact with the artificial surfaces of ECLS circuit components, assessment of clot deposition on these surfaces following clinical use is urgently needed. Scanning electron microscopy (SEM), which produces high-resolution images at nanoscale level, allows visualization and characterization of thrombotic deposits on ECLS circuitry. However, methodologies to increase the quantifiability of SEM analysis of ECLS circuit components have yet to be applied clinically. To address these issues, we developed a protocol to quantify clot deposition on ECLS membrane oxygenator gas transfer fiber sheets through digital and SEM imaging techniques. In this study, ECLS membrane oxygenator fiber sheets were obtained, fixed, and imaged after use. Following a standardized process, the percentage of clot deposition on both digital images and SEM images was quantified using ImageJ through blind reviews. The interrater reliability of quantitative analysis among reviewers was evaluated. Although this protocol focused on the analysis of ECLS membrane oxygenators, it is also adaptable to other components of the ECLS circuits such as catheters and tubing. Key features • Quantitative analysis of clot deposition using digital and scanning electron microscopy (SEM) techniques • High-resolution images at nanoscale level • Extracorporeal life support (ECLS) devices • Membrane oxygenators • Blood-contacting surfaces Graphical overview.

Long-Term Outcomes of Extracorporeal Life Support in Respiratory Failure.

Although extracorporeal life support is an expensive method with serious risks of complications, it is nowadays a well-established and generally accepted method of organ support. In patients with severe respiratory failure, when conventional mechanical ventilation cannot ensure adequate blood gas exchange, veno-venous extracorporeal membrane oxygenation (ECMO) is the method of choice. An improvement in oxygenation or normalization of acid-base balance by itself does not necessarily mean an improvement in the outcome but allows us to prevent potential negative effects of mechanical ventilation, which can be considered a crucial part of complex care leading potentially to an improvement in the outcome. The disconnection from ECMO or discharge from the intensive care unit should not be viewed as the main goal, and the long-term outcome of the ECMO-surviving patients should also be considered. Approximately three-quarters of patients survive the veno-venous ECMO, but various (both physical and psychological) health problems may persist. Despite these, a large proportion of these patients are eventually able to return to everyday life with relatively little limitation of respiratory function. In this review, we summarize the available knowledge on long-term mortality and quality of life of ECMO patients with respiratory failure.

Interaction of ceftazidime and clindamycin with extracorporeal life support.

BACKGROUND: Ceftazidime and clindamycin are commonly prescribed to critically ill patients who require extracorporeal life support such as ECMO and CRRT. The effect of ECMO and CRRT on the disposition of ceftazidime and clindamycin is currently unknown. METHODS: Ceftazidime and clindamycin extraction were studied with ex vivo ECMO and CRRT circuits primed with human blood. The percent recovery of these drugs over time was calculated to determine the degree of interaction between these drugs and circuit components. RESULTS: Neither ceftazidime nor clindamycin exhibited measurable interactions with the ECMO circuit. In contrast, CRRT cleared 100% of ceftazidime from the experimental circuit within the first 2 h. Clearance of clindamycin from the CRRT circuit was slower, with about 20% removed after 6 h. CONCLUSION: Clindamycin and ceftazidime dosing adjustments are likely required in patients who are supported with CRRT, and future studies to quantify these adjustments should consider the pathophysiology of the patient in combination with the clearance due to CRRT. Dosing adjustments to account for adsorption to ECMO circuit components are likely unnecessary and should focus instead on the pathophysiology of the patient and changes in volume of distribution. These results will help improve the safety and efficacy of ceftazidime and clindamycin in patients requiring ECMO and CRRT.

Current use of extracorporeal life support in airway surgery: a narrative review.

Background and Objective: Extracorporeal life support (ECLS) is widely used in patients with severe respiratory or cardiocirculatory failure. The most commonly used extracorporeal membrane oxygenation (ECMO) modes are veno-venous (V-V) and veno-arterial (V-A) ECMO, which can both be achieved by various types of vascular cannulation. Within the scope of tracheobronchial surgery, intraoperative ECLS may occasionally be necessary to provide sufficient oxygenation to a patient throughout a procedure, especially when conventional ventilation strategies are limited. Additionally, V-A ECMO can provide cardiopulmonary support in emergencies and in cases where hemodynamic instability can occur. Methods: This narrative literature review was carried out to identify the use and the specifics of ECLS in airway surgery over the last years. Data from 168 cases were summarized according to the indication for surgery and the mode of ECLS (V-V, V-A). Key Content and Findings: The most common tracheobronchial pathologies in which support was needed were: primary malignant disease of the airways, malignant infiltration, tracheal stenosis, injury of the airway, and congenital airway disease. With increasing experience in ECLS, the number of reported cases performed with intraoperative ECLS increased steadily over the last decade. Conclusions: A trend favoring the use of V-V ECMO over V-A ECMO was identified. These approaches should now be considered indispensable tools for managing challenging surgical cases.

Extracorporeal life support in thoracic emergencies-a narrative review of current evidence.

Background and Objective: Resuscitative therapies for respiratory and cardiac failure are lifesaving and extended by using extracorporeal life support (ECLS) as mechanical circulatory support (MSC). This review informs the debate to identify the life-threatening thoracic emergencies in which patients may be cannulated for ECLS support. Methods: An advanced search was performed in PubMed, Embase, Google Scholar, and references query, assessed in June 2022, identified 761 records. Among them, 74 publications in English were included in the current narrative review. Key Content and Findings: ECLS is an additional tool for organ support in life-threatening thoracic emergencies. It provides bridging to recovery or to decision about destination as definitive therapy, intervention, or surgery. Non-traumatic emergencies include mediastinal mass, acute lung injury (ALI), aspiration, embolisms, acute and chronic heart failure. However, based on the current evidence, trauma, and especially blunt thoracic trauma, is one of the main indications for ECLS use in thoracic emergencies, among others in chest wall fractures, blunt and penetrating lung injuries. ECLS use is always individualized to patient's needs, injury pattern and kind of organ failure, circulatory arrest inclusive, depending on if respiratory or cardiac and circulatory support is needed. Further, ECLS offers the possibility for fast volume resuscitation and rewarming, thus preventing the lethal of trauma: hypothermia, hypoperfusion and acidosis. Anticoagulation may be omitted for some hours or days. Interdisciplinary cooperation between the intensivists, surgeons, anesthesiologists, emergency medical services, an appropriately organized and trained staff, equipment resources and logistical planning are essential for successful outcomes. Conclusions: ECLS use in selected life-threatening thoracic emergencies is increasing. The summarized findings appeal to policymakers, and we hope that our summary of recommendations may impact clinical practice and research.

Management of primary graft dysfunction after lung transplantation with extracorporeal life support: an evidence-based review.

Primary graft dysfunction (PGD) is a complex inflammatory syndrome that can lead to respiratory failure after lung transplantation (LTx). The pathogenesis of PGD is multifactorial and can be driven by attributes of both the donor and recipient, perioperative characteristics, and technical handling of the graft. Despite significant advancements in patient and donor selection, perioperative management and surgical technique, PGD is still a major contributor to morbidity and mortality after lung transplant. Although there are no known durable treatment options for PGD after LTx, an increasing body of evidence and experience in high-volume lung transplant centers show that extracorporeal life support (ECLS) is a reliable option for both preventing PGD and supporting critically ill patients with PGD. Both veno-venous (V-V) ECLS and veno-arterial (V-A) ECLS are proven and feasible strategies for mitigating the morbidity and mortality associated with post-LTx PGD. In this evidence-based review, we provide an overview of the epidemiology and physiology of PGD as well as a growing body of data that supports ECLS as a major tool to manage PGD. We describe the role of ECMO in PGD prevention and management, worldwide outcomes of LTx with ECLS support, and outline our step-wise approach to managing this complex respiratory syndrome leading up to institution of ECLS.

Right ventricular dysfunction in patients with acute respiratory distress syndrome receiving venovenous extracorporeal membrane oxygenation.

Acute respiratory distress syndrome is characterized by non-cardiogenic pulmonary edema, decreased pulmonary compliance, and abnormalities in gas exchange, especially hypoxemia. Patients with acute respiratory distress syndrome (ARDS) who receive support with venovenous (V-V) extracorporeal membrane oxygenation (ECMO) usually have severe lung disease. Many patients with ARDS have associated pulmonary vascular injury which can result in elevated pulmonary vascular resistance and right heart dysfunction. Since V-V ECMO relies upon preserved cardiac function, right heart failure has important implications for patient evaluation, management, and outcomes. Worsening right heart function complicates ARDS and disease processes. Given the increasing use of ECMO to support patients with ARDS, an understanding of right ventricular-ECMO and cardiopulmonary interactions is essential for the clinician. A narrative review of the manifestations of right heart dysfunction, as well as diagnosis and management strategies for the patient with ARDS on ECMO, is provided.

Hospital ECMO capability is associated with survival in pediatric cardiac arrest.

AIM: Extracorporeal membrane oxygenation (ECMO) provides temporary support in severe cardiac or respiratory failure and can be deployed in children who suffer cardiac arrest. However, it is unknown if a hospital's ECMO capability is associated with better outcomes in cardiac arrest. We evaluated the association between pediatric cardiac arrest survival and the availability of pediatric extracorporeal membrane oxygenation (ECMO) at the treating hospital. METHODS: We identified cardiac arrest hospitalizations, including in- and out-of-hospital, in children (0-18 years old) using data from the Health Care Utilization Project (HCUP) National Inpatient Sample (NIS) between 2016 and 2018. The primary outcome was in-hospital survival. Hierarchical logistic regression models were built to test the association between hospital ECMO capability and in-hospital survival. RESULTS: We identified 1276 cardiac arrest hospitalizations. Survival of the cohort was 44%; 50% at ECMO-capable hospitals and 32% at non-ECMO hospitals. After adjusting for patient-level factors and hospital factors, receipt of care at an ECMO- capable hospital was associated with higher in-hospital survival, with an odds ratio of 1.49 [95% CI 1.09, 2.02]. Patients who received treatment at ECMO-capable hospitals were younger (median 3 years vs 11 years, p < 0.001) and more likely to have a complex chronic condition, specifically congenital heart disease. A total of 10.9% (88/811) of patients at ECMO-capable hospitals received ECMO support. CONCLUSION: A hospital's ECMO capability was associated with higher in-hospital survival among children suffering cardiac arrest in this analysis of a large United States administrative dataset. Future work to understand care delivery differences and other organizational factors in pediatric cardiac arrest is necessary to improve outcomes.