Anesthetic management of extracorporeal membrane oxygenation-supported aortic bypass surgery for atypical coarctation with severe left ventricular dysfunction: A case report.

Atypical aortic coarctation is an exceedingly rare condition, and there are very few reported cases of anesthetic management for bypass surgery in patients with severe impaired cardiac function. We present the anesthetic management of a 68-year-old woman with atypical aortic coarctation due to Takayasu arteritis and severely impaired cardiac function, who underwent ascending-to-abdominal aorta bypass surgery under extracorporeal membrane oxygenation (ECMO). The patient's severe cardiac dysfunction was due to sustained afterload from the coarctation, leading to recurrent episodes of heart failure. Surgical intervention was deemed necessary, and a decision was made to perform a bypass operation. The patient experienced a transient state of shock following induction of anesthesia, but subsequent perioperative care was safely managed with the implementation of ECMO. For bypass surgery performed on patients with severe cardiac dysfunction due to atypical coarctation of the aorta, it is crucial to prepare for potential circulatory collapse during anesthesia induction and the surgical procedure. This preparation includes meticulous planning of the anesthesia induction method and ensuring that ECMO can be established promptly if needed.

Impact of bridging veno-venous extracorporeal membrane oxygenation to COVID-19 lung transplantation.

Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) therapy is being increasingly used as respiratory support for patients with severe coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS). However, the long-term outcome of VV-ECMO as a bridge to lung transplantation in COVID-19-associated ARDS remains unclear, hence the purpose of this study aimed to evaluate its long-term outcome, safety, and feasibility. Methods: This was a retrospective cohort study from an institutional lung transplantation database between June 2020 and June 2022. Data on demographics, pre-transplantation laboratory values, postoperative outcomes, preoperative and postoperative transthoracic echocardiography findings, and survival rates were collected. Chi-square, Mann-Whitney U, Student's t, Kaplan-Meier, and Wilcoxon signed-rank tests were used for analysis. Results: Twenty-five patients with COVID-19-associated ARDS underwent lung transplant surgery with VV-ECMO bridge. Unfortunately, six patients with COVID-19-associated ARDS using VV-ECMO died while waiting for transplantation during the same study period. Patients with VV-ECMO bridge were a more severe cohort than 16 patients without VV-ECMO bridge (lung allocation score: 88.1 vs. 74.9, P<0.001). These patients had longer intensive care unit and hospital stays (P=0.03 and P=0.02, respectively) and a higher incidence of complications after lung transplantation. The one-year survival rate of patients with VV-ECMO bridge was lower than that of patients without (78.3% vs. 100.0%, P=0.06), but comparable to that of patients with other lung transplant indications (84.2%, P=0.95). Echocardiography showed a decrease in the right ventricular systolic pressure (P=0.01), confirming that lung transplantation improved right heart function. Conclusions: Our findings suggest that VV-ECMO can be used to safely bridge patients with COVID-19 associated ARDS with right heart failure.

Dynamic decline of lymphocytes predicts extracorporeal membrane oxygenation-related infections: a retrospective observational study.

Background: Limited data are available regarding the current microbiological characteristics of extracorporeal membrane oxygenation (ECMO)-related infections in intensive care units (ICUs) in China. This retrospective study aimed to determine the epidemiology, risk factors and impact on the outcome of ECMO-related infections. Methods: A retrospective observational study from January 2014 to December 2019 was performed, and adult patients receiving ECMO support for more than 48 hours were included in this study. The primary outcome was the incidence rate of ECMO-related infection. Clinical data were recorded, and risk factors associated with an increased risk of ECMO-related infection were analyzed. Results: A total of 174 adult patients who received ECMO and underwent ECMO for 1,670 days were included in this study. Forty-six patients (26.4%) developed ECMO-related infections, corresponding to 27.5 first episodes/1,000 ECMO days. The most common ECMO-related infection observed was ventilator-associated pneumonia (VAP). Infected patients had longer durations of mechanical ventilation {20.2 [interquartile range (IQR), 12.6, 30.7] vs. 9.0 (IQR, 5.8, 14.7) days, P<0.001}, ECMO support [11.6 (IQR, 8.1, 17.3) vs. 7.6 (IQR, 5.6, 9.7) days, P<0.001] and hospital stays (28.2±20.7 vs. 22.0±15.6 days, P<0.001). The factors independently associated with ECMO-related infection were a dynamic decrease in lymphocyte count [adjusted odds ratio (OR) =3.578, 95% confidence interval (CI): 2.175-4.906, P<0.001] and ECMO duration (adjusted OR =1.207, 95% CI: 1.096-1.330, P<0.001). Compared to patients without infection, infected patients had greater hospital mortality (39.1% vs. 78.3%, P<0.001) and 90-day mortality (40.6% vs. 87.0%, P<0.001). ECMO-related infections were associated with worse outcomes (adjusted Kaplan-Meier curve, log rank test P<0.001). Conclusions: Patients supported by ECMO had a high risk of developing ECMO-related infection. The most common ECMO-related infection observed was VAP. A dynamic decrease in lymphocyte counts was significantly associated with an increased risk of ECMO-related infection.

Predictors and outcomes associated with right ventricular function in patients with adult respiratory distress syndrome treated with Veno-venous extracorporeal membrane oxygenation.

INTRODUCTION: Right ventricular dysfunction is associated with mortality in patients with acute respiratory distress syndrome (ARDS) but information in veno-venous extracorporeal membrane oxygenation (ECMO) settings is limited. Study objectives were to examine factors associated with right ventricular (RV) systolic dysfunction (RVSD) and RV dilation in ECMO patients with ARDS, to compare outcomes in those with and without RVSD and RV dilation defined by qualitative and quantitative parameters, and to describe RVSD evolution during ECMO. METHODS: Retrospective observational study of adult ARDS patients supported with ECMO at a tertiary care hospital. RESULTS: Of a total of 62 patients, 56% had RVSD and 61% had RV dilation by qualitative assessment. Male gender, COVID-19, hypercarbia, and pneumothorax were associated with RVSD and RV dilation. In-hospital mortality was significantly higher in patients with RV dilation vs. no dilation (42% vs. 17%, p = .05) but comparisons for patients with and without RVSD (37% vs. 26%, respectively) did not reach statistical significance. Findings were similar when RV size and function were quantified by right to left ventricle end-diastolic area ratio and fractional area change (39% vs. 21% and 36% vs. 20% respectively; p = NS). Of 39 patients with multiple echocardiograms, 9 of 18 with initially normal RV function developed RVSD while RV function normalized in 10 of 21 patients who began ECMO with RVSD. CONCLUSIONS: Study results suggest an association of RV dilation and RVSD with worse outcomes and a dynamic nature of RV function necessitating close monitoring during the ECMO course.

Effects of different VV ECMO blood flow rates on lung perfusion assessment by hypertonic saline bolus-based electrical impedance tomography.

OBJECTIVE: Our study aimed to investigate the effects of different extracorporeal membrane oxygenation (ECMO) blood flow rates on lung perfusion assessment using the saline bolus-based electrical impedance tomography (EIT) technique in patients on veno-venous (VV) ECMO. METHODS: In this single-centered prospective physiological study, patients on VV ECMO who met the ECMO weaning criteria were assessed for lung perfusion using saline bolus-based EIT at various ECMO blood flow rates (gradually decreased from 4.5 L/min to 3.5 L/min, 2.5 L/min, 1.5 L/min, and finally to 0 L/min). Lung perfusion distribution, dead space, shunt, ventilation/perfusion matching, and recirculation fraction at different flow rates were compared. RESULTS: Fifteen patients were included. As the ECMO blood flow rate decreased from 4.5 L/min to 0 L/min, the recirculation fraction decreased significantly. The main EIT-based findings were as follows. (1) Median lung perfusion significantly increased in region-of-interest (ROI) 2 and the ventral region [38.21 (34.93-42.16)% to 41.29 (35.32-43.75)%, p = 0.003, and 48.86 (45.53-58.96)% to 54.12 (45.07-61.16)%, p = 0.037, respectively], whereas it significantly decreased in ROI 4 and the dorsal region [7.87 (5.42-9.78)% to 6.08 (5.27-9.34)%, p = 0.049, and 51.14 (41.04-54.47)% to 45.88 (38.84-54.93)%, p = 0.037, respectively]. (2) Dead space significantly decreased, and ventilation/perfusion matching significantly increased in both the ventral and global regions. (3) No significant variations were observed in regional and global shunt. CONCLUSIONS: During VV ECMO, the ECMO blood flow rate, closely linked to recirculation fraction, could affect the accuracy of lung perfusion assessment using hypertonic saline bolus-based EIT.

Early reapplication of prone position during venovenous ECMO for acute respiratory distress syndrome: a prospective observational study and propensity-matched analysis.

BACKGROUND: A combination of prone positioning (PP) and venovenous extracorporeal membrane oxygenation (VV-ECMO) is safe, feasible, and associated with potentially improved survival for severe acute respiratory distress syndrome (ARDS). However, whether ARDS patients, especially non-COVID-19 patients, placed in PP before VV-ECMO should continue PP after a VV-ECMO connection is unknown. This study aimed to test the hypothesis that early use of PP during VV-ECMO could increase the proportion of patients successfully weaned from ECMO support in severe ARDS patients who received PP before ECMO. METHODS: In this prospective observational study, patients with severe ARDS who were treated with VV-ECMO were divided into two groups: the prone group and the supine group, based on whether early PP was combined with VV-ECMO. The proportion of patients successfully weaned from VV-ECMO and 60-day mortality were analyzed before and after propensity score matching. RESULTS: A total of 165 patients were enrolled, 50 in the prone and 115 in the supine group. Thirty-two (64%) and 61 (53%) patients were successfully weaned from ECMO in the prone and the supine groups, respectively. The proportion of patients successfully weaned from VV-ECMO in the prone group tended to be higher, albeit not statistically significant. During PP, there was a significant increase in partial pressure of arterial oxygen (PaO2) without a change in ventilator or ECMO settings. Tidal impedance shifted significantly to the dorsal region, and lung ultrasound scores significantly decreased in the anterior and posterior regions. Forty-five propensity score-matched patients were included in each group. In this matched sample, the prone group had a higher proportion of patients successfully weaned from VV-ECMO (64.4% vs. 42.2%; P = 0.035) and lower 60-day mortality (37.8% vs. 60.0%; P = 0.035). CONCLUSIONS: Patients with severe ARDS placed in PP before VV-ECMO should continue PP after VV-ECMO support. This approach could increase the probability of successful weaning from VV-ECMO. TRIAL REGISTRATION: ClinicalTrials.Gov: NCT04139733. Registered 23 October 2019.

Immunomodulators in patients receiving extracorporeal membrane oxygenation for COVID-19: a propensity-score adjusted analysis of the ELSO registry.

BACKGROUND: Mortality for patients receiving extracorporeal membrane oxygenation (ECMO) for COVID-19 increased over the course of the pandemic. We investigated the association between immunomodulators and mortality for patients receiving ECMO for COVID-19. METHODS: We retrospectively analysed the Extracorporeal Life Support Organisation registry from 1 January, 2020, through 31 December, 2021, to compare the outcomes of patients who received no immunomodulators, only corticosteroids, only other immunomodulators (selective interleukin blockers, janus-kinase inhibitors, convalescent plasma, and intravenous immunoglobulin), and a combination of corticosteroids and other immunomodulators administered either before or during ECMO. We used Cox regression models to estimate survival time until 90 days. We estimated the propensity score of receiving different immunomodulators using multinomial regression, and incorporated these scores into the regression models. RESULTS: We included 7181 patients in the final analysis; 6169 patients received immunomodulators either before or during ECMO. The 90-day survival was 58.1% (95%-CI 55.1-61.2%) for patients receiving no immunomodulators, 50.7% (95%-CI 49.0-52.5%) for those receiving only corticosteroids, 62.2% (95%-CI 57.4-67.0%) for those receiving other immunomodulators, and 48.5% (95%-CI 46.7-50.4%) for those receiving corticosteroids and other immunomodulators. Compared to patients without immunomodulators, patients receiving either corticosteroids alone (HR: 1.13, 95%-CI 1.01-1.28) or with other immunomodulators (HR: 1.21, 95%-CI: 1.07-1.54) had significantly shorter survival time, while patients receiving only other immunomodulators had significantly longer survival time (HR: 0.79, 95%-CI: 0.66-0.96). The receipt of immunomodulators (across all three groups) was associated with an increase in secondary infections. CONCLUSIONS: In this cohort study, we found that immunomodulators, in particular corticosteroids, were associated with significantly higher mortality amongst patients receiving ECMO for COVID-19, after adjusting for potential confounding variables and propensity score. In addition, patients receiving corticosteroids with or without other immunomodulators had longer ECMO runs, which has potential implications for resource allocation. While residual confounding likely remains, further studies are required to evaluate the timing of immunomodulators and better understand the possible mechanisms behind this association, including secondary infections.

The impact of early perioperative heparin-free anticoagulation for extracorporeal membrane oxygenation on bleeding and thrombotic events in lung transplantation: a retrospective cohort study.

BACKGROUND: Perioperative heparin-free anticoagulation extracorporeal membrane oxygenation (ECMO) for lung transplantation is rarely reported. OBJECTIVE: To evaluate the impact of a heparin-free strategy on bleeding and thrombotic events, blood transfusion, and coagulation function during the early perioperative period and on prognosis, and to observe its effect on different ECMO types. DESIGN: A retrospective cohort study. METHODS: Data were collected from 324 lung transplantation patients undergoing early perioperative heparin-free ECMO between August 2017 and July 2022. Clinical data including perioperative bleeding and thrombotic events, blood product transfusion, coagulation indicators and 1-year survival were analysed. RESULTS: Patients were divided in venovenous (VV; n = 251), venoarterial (VA; n = 40) and venovenous-arterial (VV-A; n = 33) groups. The VV group had the lowest intraoperative bleeding and thoracic drainage within 24 h postoperatively. Vein thrombosis occurred in 30.2% of patients within 10 days postoperatively or 1 week after ECMO withdrawal, and no significant difference was found among the three groups. Double lung transplantation, increased intraoperative bleeding, and increased postoperative drainage were associated with vein thrombosis. Except for acute myocardial infarction in one patient, no other serious thrombotic events occurred. The VV-ECMO group had the lowest demand for blood transfusion. The highest prothrombin time and the lowest fibrinogen levels were observed in the VA group during ECMO run, while the highest platelet counts were found in the VV group. Both intraoperative bleeding and thoracic drainage within 24 h postoperatively were independent predictors for 1-year survival, and no thrombosis-related deaths occurred. CONCLUSION: Short-term heparin-free anticoagulation, particularly VV-ECMO, did not result in serious thrombotic events or thrombosis-related deaths, indicating that it is a safe and feasible strategy for perioperative ECMO in lung transplantation.

Effect of an evidence-based early rehabilitation program on adult patients with venovenous extracorporeal membrane oxygenation: A cohort study.

OBJECTIVES: To assess the efficacy of early rehabilitation program for VV-ECMO patients and observe the influence on the respiratory and skeletal muscles. DESIGN: A cohort study. SETTING: The study was conducted with VVECMO patients in a comprehensive ICU with 32 beds. MAIN OUTCOME MEASURES: Ultrasound measurements were performed on each patients on day 1, 4, 7, 10, and 14, including diaphragmatic excursion (DE), diaphragmatic thickening fraction (DTF), intercostal muscle thickening fraction (ICMTF), thickness of the rectus femoris (RF), thickness of vastus intermedius (VI), and rectus femoris cross-sectional area (RF-CSA). Data on basic characteristics, results of ultrasound measurements, patients outcomes and adverse events were collected. RESULTS: 22 patients received usual rehabilitation measures were set as the control group and 23 patients underwent early rehabilitation program were set as the study group. There were no differences in diaphragmatic excursion, diaphragmatic thickening fraction, intercostal muscle thickening fraction, thickness of rectus femoris, thickness of vastus intermedius, rectus femoris cross-sectional area between two groups on day 1 after VV-ECMO treatment (P > 0.05). The variation of diaphragmatic thickening fraction and intercostal muscle thickening fraction decreased on the day 7 and 14 after treatment (P < 0.05). The variation of vastus intermedius thickness and rectus femoris cross-sectional area in the study group was less compared with those in the control group on day 4, 7, 10 and 14. The ECMO duration in the study group was shorter than that in the control group (12.00 [10.00-16.25] days vs. 8.00 [6.00-12.25] days, P = 0.002), but there was no difference in the duration of mechanical ventilation. CONCLUSION: Early rehabilitation program can ameliorate muscle atrophy. We recommend implementation of our rehabilitation program in VV-ECMO patients. This program can improve skeletal muscle atrophy and dysfunction in patients with VV-ECMO effectively and perhaps improve quality of life for patients in the future. IMPLICATIONS FOR CLINICAL PRACTICE: Early rehabilitation program put higher demands bedside nurses. It requires them to observe conditions of VVECMO patients closely, assess the feasibility of rehabilitation promptly, and monitor for any adverse reactions. Ultrasound measurement is a noninvasive and useful tool to assess muscle atrophy in ICU patients. Early rehabilitation program can improve skeletal muscle atrophy and dysfunction in patients with VV-ECMO effectively.

Feasibility of veno-arterial extracorporeal life support in awake patients with cardiogenic shock.

OBJECTIVES: This study sought to demonstrate outcomes of veno-arterial extracorporeal life support (VA-ECLS) in non-intubated ("awake") patients with cardiogenic shock, as very few studies have investigated safety and feasibility in this population. METHODS: This was a retrospective review of 394 consecutive VA-ECLS patients at our institution from 2017 to 2021. We excluded patients cannulated for indications definitively associated with intubation. Patients were stratified by intubation status at time of cannulation and baseline differences were balanced by inverse probability of treatment weighting. The primary outcome was in-hospital mortality while secondary outcomes included adverse events during ECLS and destination at discharge. RESULTS: Out of 135 patients in the final cohort, 79 were intubated and 56 were awake at time of cannulation. All awake patients underwent percutaneous femoral cannulation with technical success of 100% without intubation. Indications for VA-ECLS in awake patients included acute decompensated heart failure (64.3%), pulmonary hypertension or massive pulmonary embolism (12.5%), myocarditis (8.9%), and acute myocardial infarction (5.4%). After adjustment, awake and intubated patients had similar ECLS duration (7 vs 6 days, p = 0.19), in-hospital mortality (39.6% vs 51.7%, p = 0.28), and rates of various adverse events. Intubation status was not a significant risk factor for 90-day mortality (HR [95% CI]: 1.26 [0.64, 2.45], p = 0.51) in multivariable analysis. Heart transplantation (15.1% vs 4.9%) and ventricular assist device (17.4% vs 2.2%) were more common destinations at discharge in awake patients than intubated patients (p = 0.02). CONCLUSIONS: Awake VA-ECLS is safe and feasible with comparable outcomes as intubated counterparts in select cardiogenic shock patients.

Iatrogenic HLH.

Hemophagocytic lymphohistiocytosis (HLH) can be categorized as either primary (familial, generally occurring in infants) or secondary (sHLH, occurring at any age in association with a variety of conditions) and is mainly triggered by infections, autoimmune diseases, and malignant conditions. Our understanding of the pathophysiology of sHLH is still evolving, and among the causes and associations with the syndrome, those putatively associated with iatrogenic causes remain among the most poorly understood due to the rarity of these entities and the multiple confounders so often present in the patients in whom they are reported. Herein, we present a review of the literature to describe the diagnostic and therapeutic challenges of sHLH associated with iatrogenic causes and discuss some of the challenges and future directions in our efforts to better understand these complex conditions for the advancement of patient outcomes.

Acute kidney injury as a prognostic predictor of in-hospital mortality and neurological outcomes in patients after extracorporeal cardiopulmonary resuscitation.

INTRODUCTION: Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly being applied to patients with refractory cardiac arrest, but the survival rate to hospital discharge is only approximately 29%. Because ECPR requires intensive resources, it is important to predict outcomes. We therefore investigated the prognostic association between acute kidney injury (AKI) and ECPR to confirm the performance of AKI as a prognostic predictor of in-hospital mortality and neurological outcomes in ECPR. METHODS: We conducted a retrospective observational study on patients undergoing ECPR for cardiac etiology at Chonnam National University Hospital from 2015 to 2021. The group diagnosed with AKI in any KDIGO category within the first 48 h after ECPR was compared to that without AKI, and the primary outcome of the study was in-hospital mortality. RESULTS: Of 138 enrolled patients, 83 were studied. Hospital mortality occurred in 49 patients (59%), and 55 (66.3%) showed poor neurological outcomes. The AKI group displayed significantly elevated in-hospital mortality (77.8% vs 24.1%) and poor neurological outcomes (81.5% vs 37.9%) compared to the non-AKI group (p < 0.001). Regression analysis showed that AKI was associated with significantly higher rates of both in-hospital mortality (odds ratio (OR) range 10.75-12.88) and neurologic outcomes (OR range 5.9-6.22). CONCLUSIONS: There was a significant association of AKI with both in-hospital mortality and poor neurologic outcome in patients after ECPR, and AKI can be used as an early prognostic predictor in these patients.

Ten-year trends in characteristics, management and outcomes of patients admitted with cardiogenic shock in the ACTION-SHOCK cohort.

BACKGROUND: The ACTION-SHOCK registry offers a decade-long perspective on patients admitted with cardiogenic shock (CS). AIMS: To assess trends in the management and outcomes of patients with CS over 10 years. METHODS: Trends in the characteristics, management and outcomes of patients with CS admitted into the cardiac intensive care unit of Pitié-Salpêtrière hospital from 2011 to 2020 were analysed. Short-term outcomes included in-hospital mortality, heart transplantation or ventricular assist device. Long-term outcomes were all-cause death or readmission for acute heart failure at 1 year. RESULTS: Over a 10-year period, data from 700 patients with CS (median [interquartile range] age 61 [50-72] years; 73% of men) were analysed. The proportion of CS related to acute myocardial infarction decreased (from 45% in 2011-2012 to 27% in 2019-2020) while the proportions related to chronic coronary syndrome (18% to 23%) and non-ischaemic cardiomyopathies (37 to 51%) increased (P<0.01). The use of rescue extracorporeal membrane oxygenation remained stable (19 to 14%) and intra-aortic balloon pump use decreased (22% to 7%) (P<0.01). In-hospital mortality remained stable (27 to 29%) as did the proportions of patients discharged after transplantation (17 to 14%) or with a durable ventricular assist device (2 to 4%). Among patients discharged alive, death or readmission for acute heart failure at 1 year remained high (37 to 47%). CONCLUSION: CS remained associated with a poor prognosis over the last decade. There are significant unmet needs in the management strategies of patients with CS.

The time-dependent yield of invasive vs. standard resuscitation strategies: A secondary analysis of the Prague out-of-hospital cardiac arrest study.

BACKGROUND: It is unclear how invasive resuscitative protocols may impact the time-dependent prognosis of out-of-hospital cardiac arrest (OHCA) resuscitations, or the relationship between intra-arrest transport and outcomes. METHODS: We performed a secondary analysis of the Prague OHCA Study, which randomized refractory OHCAs to "invasive" (intra-arrest transport for possible ECPR initiation) vs. "standard" resuscitation strategies (predominantly performed on-scene). Between groups, we compared outcomes of the initial resuscitation and 180- and 30-day favourable neurological outcomes (CPC 1-2), and within categories based on resuscitation duration (collapse-to-ROSC/ECPR interval). We plotted the dynamic probability of favourable outcomes with increasing durations of unsuccessful resuscitation. RESULTS: Among invasive and standard groups, respectively: 34/124 (27%) vs. 58/132 (44%) had sustained ROSC (difference -17%, 95%CI -5.0, -28); 38/124 (31%) vs. 24/132 (18%) had 30-day favourable neurological outcomes (difference 12%; 95%CI 2.0, 23); and 39/124 (31%) vs. 29/132 (22%) had 180-day favourable neurological outcomes (difference 9.5%; 95%CI -1.3, 20). For favourable outcome cases: standard group resuscitation durations were right-skewed within the first 60 min; for the invasive group the distribution was bimodal, extending to 77 min. For invasive- and standard-treated cases, the probability of favourable outcomes among those in refractory arrest at 30 min was 28% and 7.6%, respectively; declining to 0% at 77 and 60 min. CONCLUSION: In comparison to standard resuscitation, invasive strategy cases had fewer achieve sustained ROSC, however improved overall 30-day favourable neurological outcomes. While standard resuscitation yield was limited to < 60 min, invasive protocols offer a second extended window of potential successful resuscitation.

Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation.

PURPOSE: Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) frequently develop arterial hyperoxaemia, which may be harmful. However, lower oxygen saturation targets may also lead to harmful episodes of hypoxaemia. METHODS: In this registry-embedded, multicentre trial, we randomly assigned adult patients receiving VA-ECMO in an intensive care unit (ICU) to either a conservative (target SaO2 92-96%) or to a liberal oxygen strategy (target SaO2 97-100%) through controlled oxygen administration via the ventilator and ECMO gas blender. The primary outcome was the number of ICU-free days to day 28. Secondary outcomes included ICU-free days to day 60, mortality, ECMO and ventilation duration, ICU and hospital lengths of stay, and functional outcomes at 6 months. RESULTS: From September 2019 through June 2023, 934 patients who received VA-ECMO were reported to the EXCEL registry, of whom 300 (192 cardiogenic shock, 108 refractory cardiac arrest) were recruited. We randomised 149 to a conservative and 151 to a liberal oxygen strategy. The median number of ICU-free days to day 28 was similar in both groups (conservative: 0 days [interquartile range (IQR) 0-13.7] versus liberal: 0 days [IQR 0-13.7], median treatment effect: 0 days [95% confidence interval (CI) - 3.1 to 3.1]). Mortality at day 28 (59/159 [39.6%] vs 59/151 [39.1%]) and at day 60 (64/149 [43%] vs 62/151 [41.1%] were similar in conservative and liberal groups, as were all other secondary outcomes and adverse events. The conservative group experienced 44 (29.5%) major protocol deviations compared to 2 (1.3%) in the liberal oxygen group (P < 0.001). CONCLUSIONS: In adults receiving VA-ECMO in ICU, a conservative compared to a liberal oxygen strategy, did not affect the number of ICU-free days to day 28.

Three-year outcomes after bridge to transplantation ECMO-pre- and post-2018 UNOS revised heart allocation system.

BACKGROUND: Utilization of temporary mechanical circulatory support, including veno-arterial extra-corporeal membrane oxygenation as a bridge to heart transplantation (HT) has increased significantly under the revised United Network for Organ Sharing (UNOS) donor heart allocation system. The revised heart allocation system aimed to lower waitlist times and mortality for the most critically ill patients requiring biventricular, nondischargeable, mechanical circulatory support. While previous reports have shown improved 1-year post-HT survival in the current era, 3-year survival and factors associated with mortality among bridge-to-transplant (BTT) extra-corporeal membrane oxygenation (ECMO) patients are not well described. METHODS: We queried the UNOS database for all adult (age ≥ 18 years) heart-only transplants performed between 2010 and 2019. Patients were stratified as either pre- (January 2010-September 2018; era 1) or post-allocation change (November 2018-December 2019; era 2) cohort based on their HT date. Baseline recipient characteristics and post-transplant outcomes were compared. A Cox regression analysis was performed to explore risk factors for 3-year mortality among BTT-ECMO patients in era 2. For each era, 3-year mortality was also compared between BTT ECMO patients and those transplanted without ECMO support. RESULTS: During the study period, 116 patients were BTT ECMO during era 1 and 154 patients during era 2. Baseline recipient characteristics were similar in both groups. Median age was 48 (36-58 interquartile range (IQR)) years in era 2, while it was 51 (27-58 IQR) years in era 1. The majority of BTT-ECMO patients were males in both era 2 and era 1 (77.7% vs 71.5%, p = 0.28). Median ECMO run times while listed for HT were significantly shorter (4 days vs 7 days, p < 0.001) in era 2. Waitlist mortality among BTT ECMO patients was also significantly lower in era 2 (6.3% vs 19.3%, p < 0.001). Post-HT survival at 6 months (94.2% vs 75.9%, p < 0.001), 1 year (90.3% vs 74.2%, p < 0.001), and 3 years (87% vs 66.4%, p < 0.001) was significantly improved in era 2 as compared to era 1. Graft failure at 1 year (10.3% vs 25.8%, p = 0.0006) and 3 years (13.6% vs 33.6%, p = 0.0001) was also significantly lower in era 2 compared to era 1. Three-year survival among BTT ECMO patients in era 2 was similar to that of patients transplanted in era 2 without ECMO support (87% vs 85.7%, p = 0.75). In multivariable analysis of BTT-ECMO patients in era 2, every 1 kg/m2 increase in body mass index was associated with higher mortality at 3 years (hazard ratio (HR) 1.09, 95% CI 1.02-1.15, p = 0.006). Similarly, both post-HT stroke (HR 5.58, 95% CI 2.57-12.14, p < 0.001) and post-HT renal failure requiring hemodialysis (HR 4.36, 95% CI 2.43-7.82, p < 0.001) were also associated with 3-year mortality. CONCLUSIONS: Three years post-HT survival in patients bridged with ECMO has significantly improved under the revised donor heart allocation system compared to prior system. BTT ECMO recipients under the revised system have significantly shorter ECMO waitlist run times, lower waitlist mortality and 3-year survival similar to those not bridged with ECMO. Overall, the revised allocation system has allowed more rapid transplantation of the sickest patients without a higher post-HT mortality.

Planned Venovenous-Extracorporeal Membrane Oxygenation as a Bridge to Orthotopic Liver Transplant Performed for Very Severe Hepatopulmonary Syndrome: A Case Report.

Concerns related to poor oxygenation in patients with severe hepatopulmonary syndrome (HPS) may be prohibitive when considering their candidacy for liver transplantation. Extracorporeal membrane oxygenation (ECMO) has been utilized in only a few case reports as a bridge to liver transplant in patients with severe respiratory failure. We report a case of a 66-year-old man with cirrhosis and very severe (arterial oxygen pressure (PaO2) < 50 mmHg) hepatopulmonary syndrome who underwent an orthotopic liver transplant with the planned use of venovenous-ECMO. Pre-transplant echocardiography demonstrated a small-trivial patent foramen ovale (PFO) but following the resolution of hepatopulmonary shunting after liver transplantation, the PFO size enlarged and contributed to a thromboembolic stroke. We conclude that well-selected patients with HPS could benefit from the use of planned venovenous-ECMO and that a small-trivial PFO seen in a patient with HPS may warrant intervention prior to transplantation.

Congenital Heart Defects and Concurrent Diagnoses in Influenza Hospitalization in the Pediatric Health Information System Study, 2004-2019.

Influenza is associated with adverse outcomes in children, although modification by additional medical conditions is not well-documented. We aimed to compare outcomes in children with versus without congenital heart defects (CHDs) who were hospitalized for influenza. We retrospectively evaluated patients 1-18y hospitalized for influenza in the Pediatric Health Information (PHIS) database from 2004 to 2019. Outcomes were compared by CHD presence and then by CHD severity (minor biventricular, major biventricular, and single ventricle disease) using log-binomial regression adjusted for propensity scores accounting for age at admission, sex, and history of asthma. Outcomes included inpatient mortality, intensive care unit (ICU) admission, mechanical ventilation, and length of stay (LOS) > 12 days. To evaluate for effect modification by genetic diagnoses, analyses were repeated stratified by CHD and genetic diagnosis. Among 55,161 children hospitalized for influenza, 2369 (4.3%) had CHDs, including 963 with minor biventricular, 938 with major biventricular, and 468 with single ventricle CHDs. Adjusting for propensity scores, children with CHDs had higher mortality (4.1% versus 0.9%) compared to those without CHDs (risk ratio [RR] 2.5, 95% confidence interval [CI] 1.9-3.4). Children with CHDs were at higher risk of mechanical ventilation (RR 1.6, 95% CI 1.6-1.7), ICU admission (RR 1.9, 95% CI 1.8-2.1), and LOS > 12 days (RR 2.2, 95% CI 2.0-2.3). Compared to those with neither CHD nor genetic condition, children with both had significantly higher risk of all outcomes, with the largest difference for LOS > 12 days (RR 2.3, 95% CI 2.0-2.7). Children with CHDs hospitalized for influenza are particularly susceptible to adverse outcomes compared to those without CHDs. Future studies are needed to corroborate findings in light of influenza vaccination.

Racial Health Disparity Associated With Poor Pediatric Cardiac Surgery Outcomes: A Multicentered, Cross-Sectional Study.

Background: Health disparities are known to play a role in pediatric cardiac surgery outcomes. Objectives: Risk factors associated with poor clinical outcomes were assessed. Methods: Using Pediatric Health Information System Database, pediatric subjects undergoing cardiac surgery using International Classification of Diseases 10th Revision from October 2015 to December 2020 were evaluated. Subjects were categorized by case complexity using the newly validated Risk Adjustment for Congenital Heart Surgery-2 (RACHS-2). Multivariable regression analyses were conducted to ascertain risk factors. Results: A total of 59,856 subjects, median age 7.4 months (IQR: 1.5-61 months) were included; 38,917 (low), 9,833 (medium), and 11,106 (high) RACHS-2. Overall, hospital mortality was 3% and postoperative length of stay (LOS) was 7 days (IQR: 4-18 days), with significant increases in both mortality and postoperative LOS from low to high RACHS-2 scores by multivariable analysis, Kaplan-Meier, and Cox regression. Mechanical ventilation, extracorporeal membrane oxygenation, infection, and surgical complication were most significantly associated with increased mortality by 1.198 to 10.227 times (P < 0.008). After controlling for these significant variables as well as RACHS-2, age at surgery and emergency/urgent admission type, multivariable analysis revealed that non-White race was associated with increased mortality (relative risk: 1.2, 95% CI: 0.729-0.955, P = 0.008) and increased postoperative LOS by 1.04 days (95% CI: 0.95-0.97, P < 0.001). This significant increase in both clinical outcomes was concordant in non-White neonates (mortality relative risk: 1.3, 95% CI: 1.1-1.6, P = 0.003; and postoperative LOS by 2.05 weeks (95% CI: 1.36-3.10, P < 0.001). Conclusions: The influence of racial differences in neonates and children should be further evaluated to mitigate any disparity in those undergoing cardiac surgery.