ObjectiveVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary circulatory and respiratory support allowing hemodynamic stabilization during high-risk transcatheter aortic valve replacement (TAVR). However, the optimal timing of VA-ECMO use in high-risk TAVR remains controversial. We aimed to report our experience using a novel standby ECMO strategy during high-risk TAVR.MethodsWe retrospectively evaluated consecutive patients who received high-risk TAVR with standby ECMO between March 1,2023 and March 1,2024 at the Beijing Anzhen Hospital. Small, 5F or 6F sheaths were placed in ipsilateral femoral vein and artery before TAVR procedures. The primary outcome of this study was survival to hospital discharge with good neurological recovery defined as cerebral performance category (CPC) 1-2.ResultsA total of 24 patients undergoing high-risk TAVR with standby ECMO were included. Six (25.0%) of the 24 patients with standby ECMO suffered from cardiogenic shock or cardiac arrest and required emergency VA-ECMO institution. The median (IQR) cannulation time was 8 (6-11) minutes, and the median (IQR) ECMO duration was 35 (24-48) hours. All of the 24 patients underwent successful TAVR procedures and survival to hospital discharge with CPC1-2.ConclusionsStandby ECMO with preset femoral vascular sheaths was feasible and effective for refractory cardiogenic shock and cardiac arrest during high-risk TAVR.

RationaleFor veno-arterial extracorporeal membrane oxygenation (ECMO), the femoral artery is the preferred cannulation site (femoro-femoral: Vf-Af). This results in retrograde aortic flow, which increases the left ventricular afterload and can lead to severe pulmonary edema and thrombosis of the cardiac chambers. Right axillary artery cannulation (femoral-axillary: Vf-Aa) provides partial anterograde aortic flow, which may prevent some complications. This study aimed to compare the 90-day mortality and complication rates between VF-AA and VF-AF.MethodsConsecutive adult patients with cardiogenic shock who received peripheral VA-ECMO between 2013 and 2019 at our institution were retrospectively included. The exclusion criteria were refractory cardiac arrest, multiple VA-ECMO implantations due to vascular access changes, weaning failure, or ICU readmission. A statistical approach using inverse probability of treatment weighting was used to estimate the effect of the cannulation site on the outcomes. The primary endpoint was the 90-day mortality. The secondary endpoints were vascular access complications, stroke, and other complications related to retrograde blood flow. Outcomes were estimated using logistic regression analysis.ResultsVA-ECMO was performed on 534 patients. Patients with refractory cardiac arrest (n = 77 (14%)) and those supported by multiple VA-ECMO (n = 92, (17%)) were excluded. Out of the 333 patients studied (n = 209 Vf-Aa; n = 124 VF-AF), the main indications for VA-ECMO implantation were post-cardiotomy (33%, n = 109), dilated cardiomyopathy (20%, n = 66), post-cardiac transplantation (15%, n = 50), acute myocardial infarction (14%, n = 46) and other etiologies (18%, n = 62). The median SOFA score was 9 [7-11], and the crude 90-day mortality rate was 53% (n = 175). After IPTW, the 90-day mortality was similar in the Vf-Aa and VF-AF groups (54% vs 58%, IPTW-OR = 0.84 [0.54-1.29]). Axillary artery cannulation was associated with significantly fewer local infections (OR = 0.21, 95% CI:0.09-0.51), limb ischemia (OR = 0.37, 95% CI:0.17-0.84), bowel ischemia (OR = 0.16, 95% CI:0.05-0.51) and pulmonary edema (OR = 0.52, 95% CI:0.29-0.92) episodes, but with a higher rate of stroke (OR = 2.87, 95% CI:1.08-7.62) than femoral artery cannulation.ConclusionCompared to VF-AF, axillary cannulation was associated with similar 90-day mortality rates. The high rate of stroke associated with axillary artery cannulation requires further investigation.

Long-term outcomes and quality of life have been identified as core patient-centered outcomes for venoarterial extracorporeal membrane oxygenation (VA-ECMO) research. The aim of this study is to investigate the incidence of death or new disability at 12 months after the initiation of VA-ECMO.

Prospective, multicenter, registry-embedded cohort study in 26 hospitals in Australia and New Zealand from February 2019 through April 2023. Adult patients admitted to a participating ICU and who underwent VA-ECMO were included. The primary outcome was death or new disability at 6 and 12 months. All results were adjusted for patient characteristics at the time of ECMO initiation.

Among 389 patients who received VA-ECMO (median age, 57 [44-65] years; 35% female), the incidence of death or new disability at 12 months was 70.6% compared with 70.8% at 6 months (adjusted odds ratio for 12 versus 6 months, 0.61 [95% CI, 0.25-1.49]; P=0.27). Compared with 6 months, at 12 months after VA-ECMO more patients were independent in activities of daily living (62.1% versus 48.2%; adjusted odds ratio, 2.84 [95% CI, 1.50-5.36]; P=0.001), and fewer patients were unemployed due to health reasons (32.7% versus 47.4%; adjusted odds ratio, 0.29 [95% CI, 0.13-0.65]; P<0.001). Differences in outcomes were found according to the reason for VA-ECMO initiation.

At 12 months after VA-ECMO, 30% of patients are alive and without disability, with differences in outcome associated with the reason for VA-ECMO initiation. The major burden of disability appears to develop in the first 6 months after VA-ECMO initiation and is sustained between 6 and 12 months.

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03793257.

The long-term effects of early left ventricular (LV) unloading after venoarterial extracorporeal membrane oxygenation (VA-ECMO) remain unclear.

The EARLY-UNLOAD trial was a single-centre, investigator-initiated, open-label, randomized clinical trial involving 116 patients with cardiogenic shock (CS) undergoing VA-ECMO. The patients were randomly assigned to undergo either early routine LV unloading by transseptal left atrial cannulation within 12 h after randomization or the conventional approach, which permitted rescue transseptal cannulation in case of an increased LV afterload. The pre-specified secondary endpoints at 1 year included all-cause mortality, cardiac mortality, non-cardiac mortality, rehospitalization for heart failure (HF), and the composite of all-cause mortality or rehospitalization for HF. At 1 year, data for 114 of 116 patients (98.3%) were available for analysis. All-cause death had occurred in 33 of 58 patients (56.9%) in early group and 32 of 56 patients (57.1%) in conventional group {hazard ratio [HR], 0.97 [95% confidence interval (CI), 0.60 to 1.58], P = 0.887}. There was no significant difference in cardiac or non-cardiac mortality. Among 61 survivors at 30 days, the incidence of rehospitalization for HF at 1 year was comparable between two groups [HR, 1.17 (95% CI 0.43 to 3.24), P = 0.758]. The incidence of the composite outcome of all-cause mortality or rehospitalization for HF also did not differ between the groups [HR, 1.01 (95% CI 0.69 to 1.76), P = 0.692].

Among patients with CS undergoing VA-ECMO, early routine LV unloading did not improve clinical outcomes at 1 year of follow-up.

ClinicalTrials.gov: NCT04775472.

Background: Pheochromocytoma and paraganglioma are catecholamine-secreting tumors, rarely presenting with pheochromocytoma multisystem crisis (PMC), a life-threatening endocrine emergency. The severity of the condition includes a refractory cardiogenic shock and may therefore require the use of temporary mechanical circulatory support. The aim of this review is to describe the incidence of pheochromocytoma and paraganglioma crises associated with refractory cardiogenic shock, the physiopathological impact of this condition on the myocardial function, the role of temporary mechanical circulatory support (tMCS) in its management, and the outcomes of this specific population. Methods: For the purpose of this narrative review, a literature search of PubMed was conducted as of 16 November 2024. Medical Subject Headings (MeSH) terms used included extracorporeal circulation", "Impella", "pheochromocytoma", "paraganglioma", and "cardiogenic shock", combined with Boolean "OR" and "AND". Data from case series, retrospective studies, and systematic reviews were considered. Seven studies reporting on 45 patients who developed PMC with cardiogenic shock requiring tMCS were included. Patients were young, with a median age of 43 years (range 25-65) at presentation. Most cases presented with severe hemodynamic instability, blood pressure lability, and rapid progression to severe left ventricular dysfunction. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was the most common tMCS used to stabilize patients, initiate specific pheochromocytoma treatments, and, in some cases, provide circulatory support during emergent surgery. The median duration of VA-ECMO support was 4 days (range 1-7) and the reported mean in-hospital survival rate was 93.5%. Following VA-ECMO weaning, survivors showed full recovery of the left ventricular ejection fraction (LVEF). Conclusions: The cardiac dysfunction observed in PMC-associated cardiogenic shock may be severe and life-threatening but appears reversible. tMCS should therefore be considered in eligible cases, as a bridge to recovery, treatment, or surgery. The reported survival rates are impressively high, suggesting possibly a substantial risk of publication bias.

Cardiogenic shock carries high mortality. This study investigated the relationship between protocol-advocated best practices and outcomes.

Patients with cardiogenic shock supported by Impella CP in an Asian tertiary cardiac center were evaluated for 30-day post percutaneous ventricular assist device (PVAD) survival after adopting a standardized protocol emphasizing early mechanical circulatory support (shock-to-PVAD time ≤180 minutes), pulmonary artery catheterization for invasive hemodynamics, and safe vascular access.

Of 109 consecutive patients (mean age 58.5±11.2, 80.7% male, 67% acute myocardial infarction, 33% acute decompensated heart failure), 45 (41.3%), 33 (30.3%), and 31 (28.4%) were in SCAI Shock Stages C, D, and E, respectively. A suggestive trend of improving 30-day survival was observed (56.8%, 63.9%, and 72.2% in successive one thirds, P1, P2, and P3 of patients), paralleling a similar trend in achievement of best practices. Patients achieving all 3 best practices significantly increased from 35.1% (P1) to 52.8% (P3) (P=0.026). Median shock-to-PVAD time reduced from 5 [interquartile range: 2-23] hours (P1) to 1.5 [1-5] hours (P3) (P for trend=0.014), whereas pulmonary artery catheterization utilization (80.6-86.1%) and device-related major vascular complications (5.6-8.4%) remained relatively stable. Achieving more best practices was significantly associated with better 30-day survival, with patients achieving all 3, 2, and ≤1 best practices had 30-day survival rates of 75.0%, 63.6%, and 35.7%, respectively (P=0.043). In multivariate Cox regression analysis, shock-to-PVAD time >180 minutes remained an independent predictor of mortality (P=0.031).

Achievement of protocol-advocated best practices, especially early shock recognition and prompt PVAD support in appropriate patients, was associated with improved outcomes with PVAD use in cardiogenic shock. Future studies are suggested to confirm the benefits of a protocolized approach and evaluate the value of individual best practices.

Spine surgery, particularly deformity correction, is associated with a high risk of peri-operative or post-operative complications, and these complications can lead to catastrophic consequences. This case report will present the etiology and treatment process of the peri-operative cardiac arrest during scoliosis correction surgery.

In this report, we present a case of cardiac arrest during posterior correction surgery in a 17-year-old female patient with adolescent idiopathic scoliosis.

The patient was successfully treated using extracorporeal membrane oxygenation and an intra-aortic balloon pump. We have discussed the potential causes of peri-operative cardiac arrest, including thromboembolism (VAE/PE), electrolyte imbalance (Hyper/Hypokalemia or Acidosis), hypovolemia, hypothermia, and cardiogenic shock related to neurogenic-stunned myocardium.

There are many etiologies should be considered in peri-operative cardiac arrest during posterior correction spine surgery, such as venous air embolism and electrolyte imbalance. Stress cardiomyopathy, which occurs after stressful conditions, such as surgery should also be considered. Surgeons must consider these etiologies when faced with critical situations, and the successful treatment of such cases relies on team collaboration and prompt intervention.

Cardiogenic shock (CS) is a severe complication of acute coronary syndrome (ACS) with mortality rates approaching 50%. The ability to identify high-risk patients prior to the development of CS may allow for pre-emptive measures to prevent the development of CS. The objective was to derive and externally validate a simple, machine learning (ML)-based scoring system using variables readily available at first medical contact to predict the risk of developing CS during hospitalization in patients with ACS.

Observational multicentre study on ACS patients hospitalized at intensive care units. Derivation cohort included over 40 000 patients from Beth Israel Deaconess Medical Center, Boston, USA. Validation cohort included 5123 patients from the Sheba Medical Center, Ramat Gan, Israel. The final derivation cohort consisted of 3228 and the final validation cohort of 4904 ACS patients without CS at hospital admission. Development of CS was adjudicated manually based on the patients' reports. From nine ML models based on 13 variables (heart rate, respiratory rate, oxygen saturation, blood glucose level, systolic blood pressure, age, sex, shock index, heart rhythm, type of ACS, history of hypertension, congestive heart failure, and hypercholesterolaemia), logistic regression with elastic net regularization had the highest externally validated predictive performance (c-statistics: 0.844, 95% CI, 0.841-0.847).

STOP SHOCK score is a simple ML-based tool available at first medical contact showing high performance for prediction of developing CS during hospitalization in ACS patients. The web application is available at https://stopshock.org/#calculator.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for cardiogenic shock (CS) in adults, with age-influencing outcomes. Data from the Chinese Extracorporeal Life Support (CSECLS) Organization registry (January 2017-July 2023) were analyzed to assess in-hospital mortality in VA-ECMO for CS. Patients ≤65 years were categorized as young, and those >65 as elder. The primary outcome was in-hospital mortality, with secondary outcomes including ECMO weaning, 30 day survival, and complications. Of 5,127 patients, the young group (73.4%) had a median age of 51.0 (40.0-58.0) years, and the elder group (26.6%) had a median age of 71.0 (68.0-75.0) years. The in-hospital mortality was lower in the younger group (45.1%) compared with the elder group (52.6%, p < 0.001). The young group also had higher ECMO weaning rates (79.4% vs. 74.8%, p < 0.001) and 30 day survival (59.1% vs. 51.3%, p < 0.001). Bleeding, renal, and pulmonary complications were more frequent in young patients, though not statistically significant. Young patients undergoing VA-ECMO for CS generally have better outcomes than older patients, though careful selection is crucial to manage complications.

Objective : To evaluate if mechanical left ventricular unloading could reduce mortality in patients with cardiogenic shock undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO). Methods : We searched MEDLINE, Embase, and the Cochrane Library for randomized controlled trials and propensity score-matched studies published until December 20, 2023. The primary outcome was mortality at the longest follow-up. We used a Mantel-Haenszel random effects meta-analysis and reported the pooled results with a risk ratio (RR) and 95% confidence interval (CI). The review protocol was registered on PROSPERO International prospective register of systematic review (CRD42024498665). Results : We identified two randomized controlled trials and 11 propensity score-matched studies, totaling 9,858 patients. Mechanical left ventricular unloading was significantly associated with reduced mortality at the longest follow-up (RR, 0.89; 95% CI, 0.84-0.94; P = 0.0001; moderate certainty of evidence), which was confirmed in studies using intra-aortic balloon pump. Benefits of mechanical unloading were also observed in terms of successful VA-ECMO weaning (RR, 1.15; 95% CI, 1.02-1.29; P = 0.02; low certainty of evidence) and favorable neurological outcome (two studies; RR, 2.45; 95% CI, 1.62-3.69; P < 0.0001; low certainty of evidence), although we observed an increased incidence of major bleeding (RR, 1.27; 95% CI, 1.02-1.59; P = 0.03; low certainty of evidence) and hemolysis (RR, 1.49; 95% CI, 1.10-2.02; P = 0.01; moderate certainty of evidence). Conclusions : Among adult patients with cardiogenic shock treated with VA-ECMO, mechanical left ventricular unloading was associated with reduced mortality, which was confirmed in studies using intra-aortic balloon pump as an unloading device.

Limited data exist on echocardiographic predictors of weaning from veno-arterial extracorporeal membrane oxygenation (V-A ECMO). We aimed to test the performance of different echocardiographic indices to predict weaning from V-A ECMO and free survival after weaning.

Observational study including patients with cardiogenic shock submitted to V-AECMO. Echocardiography was performed after V-AECMO placement and daily during the weaning trial to assess cardiac recovery. Echocardiography data after V-A ECMO implantation and during the last weaning trial before V-A ECMO removal were analysed. Besides traditional parameters, total isovolumic time (t-IVT, a left ventricular performance index) and mitral annular plane systolic excursion (MAPSE) were also tested. Seventy-six patients were included. A greater ventricular velocity time integral (LVOT VTI) at baseline was associated with a five-fold increase in weaning success (P < 0.001) as MAPSE lateral >6.15 mm (P = 0.001) did. TAPSE and S' at tricuspid annulus showed an analogous association. During the weaning trial t-IVT, LVEF, MAPSE, LVOT VTI, and TAPSE all improved significantly (P < 0.001 for all). At regression analysis t-IVT <14.4 s/min (<0.001), LVOT VTI >12.3 cm (P < 0.001), MAPSE > 8.9 mm (P < 0.001), TAPSE > 16 mm (<0.001), and E/e' < 15.5 (P = 0.001) were associated with weaning success and free survival after weaning. LVEF did not predict the weaning success and survival at any time-point (P = 0.230).

Longitudinal function, t-IVT and native ejection, measured with LVOT VTI, are reliable parameters to predict weaning success in V-A ECMO whereas the LVEF, although dynamically changing during weaning trial, it is not.

Acute myocardial infarction-associated cardiogenic shock (AMICS) remains a condition with high mortality. Some patients require mechanical circulatory support (MCS) as their condition deteriorates. Sex-specific differences in risk factors and outcomes of cardiovascular disease have previously been described but are inconclusive regarding the use of MCS in AMICS. We aimed to investigate these with a focus on long-term outcomes. Health claim data from AOK - Die Gesundheitskasse (local health care funds) for patients hospitalized with AMICS between January 1, 2014, and December 31, 2015, was descriptively analyzed. Then, a Cox proportional hazards model was used to adjust for confounders. We analyzed 10,023 patients, of which 477 (4.8%) were treated with veno-arterial extra-corporeal membrane oxygenation (V-A ECMO). In-hospital mortality was high, but similar between treatments (V-A ECMO 59.1%, no V-A ECMO 56.6%). Women had a higher median age (78.9 years, IQR 13.8 vs. 71.8 years, IQR 17.9; p < 0.001), a different cardiovascular risk profile and in the conservatively treated patients underwent revascularization less often (69.2% vs. 77.1%; p < 0.001) than men did. In a multivariate analysis, female sex was not associated with lower survival (HR 1.03, CI 0.98-1.09; p = 0.233). V-A ECMO, however, was associated with lower survival in both sexes. We observed a low overall survival in follow-up after three years (no V-A ECMO: men 28.9% vs. women 21.7%, V-A ECMO: men 18.2% vs. women 17.0%). In conclusion, women with AMICS presented with a different risk profile, especially a higher age, and underwent guideline-recommended therapies such as revascularization less often than men. Female sex, however, was not associated with lower survival in a multivariate analysis. In-hospital mortality was high, regardless of treatment, and V-A ECMO was associated with lower survival in follow-up.

The role of intra-aortic balloon pump (IABP) combined with venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock (CS) remains unclear. This study investigated the effect of applying IABP for left ventricle (LV) unloading after VA-ECMO on reducing mortality in patients with CS.

Data from 5,492 consecutive patients with CS treated with VA-ECMO between January 2017 and July 2023 were collected from the CSECLS registry. The primary outcome was in-hospital mortality. The secondary outcomes included 30-day mortality, survival on VA-ECMO, and various complications. The association between the application of IABP after VA-ECMO and in-hospital outcomes was assessed.

Among 5,492 patients undergoing VA-ECMO (mean age 54.7 ± 15.1 years, 3,917 [71.3%] male), 832 (15.1%) received IABP after VA-ECMO. Before VA-ECMO, a higher incidence of cardiac intervention (13.9% vs. 16.7%) and myocardial infarction (12.0% vs. 14.8%) (all P < 0.05) was seen in the IABP after VA-ECMO group. In this cohort, the IABP after VA-ECMO group had a lower in-hospital mortality (52.5% vs. 48.0%, P = 0.017) and a higher survival rate on VA-ECMO (75.4% vs. 79.4%, P = 0.014). On multivariate modeling, the use of IABP after VA-ECMO was associated with a lower risk of in-hospital mortality (adjusted odds ratio[aOR], 0.823 [95% confidence interval [CI], 0.686-0.987]; P = 0.035) and on-support mortality (aOR, 0.828 [95% CI, 0.688-0.995]; P = 0.044). However, the use of IABP after VA-ECMO was also associated with an increased incidence of complications, including mechanical (aOR: 1.905, [95% CI, 1.278-2.839]; P = 0.002), bleeding (aOR: 1.371, [95% CI, 1.092-1.721]; P = 0.007), renal (aOR: 1.252, [95% CI, 1.041-1.505]; P = 0.017), and pulmonary (aOR: 1.768, [95% CI, 1.446-2.163]; P < 0.001).

In this multicenter retrospective study, the use of IABP after VA-ECMO was associated with lower in-hospital mortality in patients with CS. These findings suggest that IABP may offer advantages for LV unloading in patients with CS treated with VA-ECMO, but further validation through randomized controlled trials is warranted to better understand the balance of risks and benefits.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used to treat medically refractory cardiogenic shock and cardiac arrest, and its usage has increased exponentially over time. Although VA-ECMO has many advantages over other mechanical circulatory supports, it has the unavoidable disadvantage of increasing retrograde arterial flow in the afterload, which causes left ventricular (LV) overload and can lead to undesirable consequences during VA-ECMO treatment. Weak or no antegrade flow without sufficient opening of the aortic valve increases the LV end-diastolic pressure, and that can cause refractory pulmonary edema, blood stagnation, thrombosis, and refractory ventricular arrhythmia. This hemodynamic change is also related to an increase in myocardial energy consumption and poor recovery, making LV unloading an essential management issue during VA-ECMO treatment. The principal factors in effective LV unloading are its timing, indications, and modalities. In this article, we review why LV unloading is required, when it is indicated, and how it can be achieved.

Extracorporeal membrane oxygenation is increasingly being used to support patients with hypoxemic respiratory failure and cardiogenic shock. During the COVID-19 pandemic, consensus guidance recommended extracorporeal life support for patients with COVID-19-related cardiopulmonary disease refractory to optimal conventional therapy, prompting a substantial expansion in the use of this support modality. Extracorporeal membrane oxygenation was particularly integral to the bridging of COVID-19 patients to heart or lung transplantation. Limited human and physical resources precluded widespread utilization of mechanical support during the COVID-19 pandemic, necessitating careful patient selection and optimal management by expert healthcare teams for judicious extracorporeal membrane oxygenation use. This review outlines the evidence supporting the use of extracorporeal life support in COVID-19, describes the practice and outcomes of extracorporeal membrane oxygenation for COVID-19-related respiratory failure and cardiogenic shock, and proposes lessons learned for the implementation of extracorporeal membrane oxygenation as a bridge to transplantation in future public health emergencies.

Cardiogenic shock is a multisystem pathology that carries a high mortality rate, and initial pharmacotherapies include the use of vasopressors and inotropes. These agents can increase myocardial oxygen consumption and decrease tissue perfusion that can oftentimes result in a state of refractory cardiogenic shock for which temporary mechanical circulatory support can be considered. Numerous support devices are available, each with its own hemodynamic blueprint. Defining a patient's hemodynamic profile and understanding the phenotype of cardiogenic shock is important in device selection. Careful patient selection incorporating a multidisciplinary team approach should be utilized.

Cardiogenic shock is a clinical syndrome caused by primary heart disease that results in decreased cardiac output and insufficient systemic perfusion. A study was conducted to determine what factors affect survival in patients with cardiogenic shock treated with extracorporeal membrane oxygenation (ECMO).

A systematic search was conducted across various databases, including CKNI, VIP, Wan Fang, CBM, Embase, PubMed, Cochrane Library, and Web of Science databases, to gather factors linked to the prognosis of patients with cardiogenic shock who underwent ECMO treatment. The search period for each database was set to conclude on April 30, 2024.

The findings suggest that, in comparison to the death group, the lactic acid levels of the survival group after treatment were significantly lower (95% confidence interval [CI]: -0.79, -0.58). In addition, the creatinine levels of the survival group after treatment were also significantly lower than those of the death group (95% CI: -0.39, -0.14). Furthermore, the troponin levels in the survival group after treatment were lower than those in the death group (95% CI: -0.32, 0.04), and the total bilirubin levels in the survival group after treatment were also lower than those in the death group (95% CI: -0.62, -0.23).

According to the study, total bilirubin, creatinine, and lactic acid levels were lower in the survival group than in the death group when ECMO was used to treat cardiogenic patients, suggesting a better prognosis for patients with cardiogenic shock. Therefore, total bilirubin, creatinine, and lactic acid could be influential factors in the prognosis of survival in patients with cardiogenic shock.

Cardiogenic shock due to acute myocardial infarction (AMI-CS) is associated with significant short- and long-term morbidity and mortality. Despite this, little is known about associated cost.

The purpose of this study was to evaluate the health care costs and resource use associated with AMI-CS using administrative data from the province of Ontario, Canada.

This was a retrospective cohort study of adult patients with AMI-CS from April 2009 to March 2019. One-year costs following index admission were reported at an individual level. We used generalized linear models to identify factors associated with increased cost. We stratified patients by revascularization strategy to compare cost in each group and examined total cost at a patient level per individual fiscal year.

We included 9,789 consecutive patients with AMI-CS across 135 centers in Ontario (mean age 70.5 years; 67.7% male). Mortality in-hospital was 30.2%, and mortality at 2 years was 45.9%. The median inpatient cost per patient was $23,912 (IQR: $12,234-$41,833) with a median total 1-year cost of $37,913 (IQR: $20,113-$66,582). The median 1-year cost was $17,730 (IQR: $9,323-$38,379) for those who died in hospital, and $45,713 (IQR: $29,688-$77,683) for those surviving to discharge, with $12,719 (IQR: $4,262-$35,275) occurring after discharge. Patients who received coronary artery bypass grafting incurred the highest cost among revascularization groups. No significant differences were observed in cost per fiscal year from 2009 to 2019.

AMI-CS is associated with significant health care costs, both during the index hospitalization and following discharge. To optimize cost-effectiveness, future therapies should aim to reduce disability in addition to improving mortality.

Patients with refractory cardiogenic shock (CS) necessitating peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) often require an intra-aortic balloon pump (IABP) or Impella for unloading; however, comparative effectiveness data are currently lacking.

Using Diagnosis Procedure Combination data from approximately 1,200 Japanese acute care hospitals (April 2018-March 2022), we identified 940 patients aged ≥18 years with CS necessitating peripheral VA-ECMO along with IABP (ECMO-IABP; n=801) or Impella (ECPella; n=139) within 48 h of admission. Propensity score matching (126 pairs) indicated comparable in-hospital mortality between the ECPella and ECMO-IABP groups (50.8% vs. 50.0%, respectively; P=1.000). However, the ECPella cohort was on mechanical ventilator support for longer (median [interquartile range] 11.5 [5.0-20.8] vs. 9.0 [4.0-16.8] days; P=0.008) and had a longer hospital stay (median [interquartile range] 32.5 [12.0-59.0] vs. 23.0 [6.3-43.0] days; P=0.017) than the ECMO-IABP cohort. In addition, medical costs were higher for the ECPella than ECMO-IABP group (median [interquartile range] 9.09 [7.20-12.20] vs. 5.23 [3.41-7.00] million Japanese yen; P<0.001).

Our nationwide study could not demonstrate compelling evidence to support the superior efficacy of Impella over IABP in reducing in-hospital mortality among patients with CS necessitating VA-ECMO. Further investigations are imperative to determine the clinical situations in which the potential effect of Impella can be maximized.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has become a common intervention for patients with cardiogenic shock (CS), often complicated by cardiac arrest (CA). Moderate hypothermia (MH) has shown promise in mitigating ischemia-reperfusion injury following CA. The HYPO-ECMO trial aimed to compare the effect of MH versus normothermia in refractory CS rescued by VA-ECMO. The primary aim of this non-predefined post hoc study was to assess the treatment effect of MH in the subgroup of patients with cardiac arrest (CA) within the HYPO-ECMO trial. Additionally, we will evaluate the prognostic significance of CA in these patients.

This post hoc analysis utilized data from the randomized HYPO-ECMO trial conducted across 20 French cardiac shock care centers between October 2016 and July 2019. Participants included intubated patients receiving VA-ECMO for CS for less than 6 h, with 334 patients completing the trial. Patients were randomized to early MH (33-34 °C) or normothermia (36-37 °C) for 24 h.

Of the 334 patients, 159 (48%) experienced preceding CA. Mortality in the CA group was 50.9% at 30 days and 59.1% at 180 days, compared to 42.3% and 51.4% in the no-CA group, respectively (adjusted risk difference [RD] at 30 days, 8.1% [-0.8 to 17.1%], p = 0.074 and RD at 180 days 7.0% [-3.0 to 16.9%], p = 0.17). MH was associated with a significant reduction in primary (RD -13.3% [-16.3 to -0.3%], p = 0.031) and secondary outcomes in the CA group only (p < 0.025 for all), with a significant interaction between MH and CA status for 180-day mortality [p = 0.03].

This post hoc analysis suggests that MH shows potential for reducing mortality and composite endpoints in patients with cardiac arrest and refractory CS treated with VA-ECMO without an increased risk of severe bleeding or infection. Further research is needed to validate these findings and elucidate underlying mechanisms.

This study evaluates the clinical trends, risk factors, and effects of post-transplant stroke and subsequent functional independence on outcomes following orthotopic heart transplantation under the 2018 heart allocation system.

The United Network for Organ Sharing registry was queried to identify adult recipients from October 18, 2018 to December 31, 2021. The cohort was stratified into 2 groups with and without post-transplant stroke. The incidence of post-transplant stroke was compared before and after the allocation policy change. Outcomes included post-transplant survival and complications. Multivariable logistic regression was performed to identify risk factors for post-transplant stroke. Sub-analysis was performed to evaluate the impact of functional independence among recipients with post-transplant stroke.

A total of 9,039 recipients were analyzed in this study. The incidence of post-transplant stroke was higher following the policy change (3.8% vs 3.1%, p = 0.017). Thirty-day (81.4% vs 97.7%) and 1-year (66.4% vs 92.5%) survival rates were substantially lower in the stroke cohort (p < 0.001). The stroke cohort had a higher rate of post-transplant renal failure, longer hospital length of stay, and worse functional status. Multivariable analysis identified extracorporeal membrane oxygenation, durable left ventricular assist device, blood type O, and redo heart transplantation as strong predictors of post-transplant stroke. Preserved functional independence considerably improved 30-day (99.2% vs 61.2%) and 1-year (97.7% vs 47.4%) survival rates among the recipients with post-transplant stroke (p < 0.001).

There is a higher incidence of post-transplant stroke under the 2018 allocation system, and it is associated with significantly worse post-transplant outcomes. However, post-transplant stroke recipients with preserved functional independence have improved survival, similar to those without post-transplant stroke.

Extracorporeal membrane oxygenation (ECMO) is a rescue therapy in patients with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19. While bleeding and thrombosis complicate ECMO, these events may also occur secondary to COVID-19. Data regarding bleeding and thrombotic events in COVID-19 patients on ECMO are sparse.

Using the COVID-19 Critical Care Consortium database, we conducted a retrospective analysis on adult patients with severe COVID-19 requiring ECMO, including centers globally from 01/2020 to 06/2022, to determine the risk of ICU mortality associated with the occurrence of bleeding and clotting disorders.

Among 1,248 COVID-19 patients receiving ECMO support in the registry, coagulation complications were reported in 469 cases (38%), among whom 252 (54%) experienced hemorrhagic complications, 165 (35%) thrombotic complications, and 52 (11%) both. The hazard ratio (HR) for Intensive Care Unit mortality was higher in those with hemorrhagic-only complications than those with neither complication (adjusted HR = 1.60, 95% CI 1.28-1.99, p < 0.001). Death was reported in 617 of the 1248 (49.4%) with multiorgan failure (n = 257 of 617 [42%]), followed by respiratory failure (n = 130 of 617 [21%]) and septic shock [n = 55 of 617 (8.9%)] the leading causes.

Coagulation disorders are frequent in COVID-19 ARDS patients receiving ECMO. Bleeding events contribute substantially to mortality in this cohort. However, this risk may be lower than previously reported in single-nation studies or early case reports. Trial registration ACTRN12620000421932 ( https://covid19.cochrane.org/studies/crs-13513201 ).

Venoarterial extracorporeal membrane oxygenation (ECMO) is a key treatment method used with patients in cardiac arrest who do not respond to medical treatment. A critical step in initiating therapy is the insertion of ECMO cannulas. Peripheral ECMO cannulation methods have been preferred for extracorporeal cardiopulmonary resuscitation (ECPR).

Patients who underwent ECPR at Daegu Catholic University Medical Center between January 2017 and May 2023 were included in this study. We analyzed the impact of 2 different peripheral cannulation strategies (surgical cutdown vs. percutaneous cannulation) on various factors, including survival rate.

Among the 99 patients included in this study, 66 underwent surgical cutdown, and 33 underwent percutaneous insertion. The survival to discharge rates were 36.4% for the surgical cutdown group and 30.3% for the percutaneous group (p=0.708). The ECMO insertion times were 21.3 minutes for the surgical cutdown group and 10.3 minutes for the percutaneous group (p<0.001). The factors associated with overall mortality included a shorter low-flow time (hazard ratio [HR], 1.045; 95% confidence interval [CI], 1.019-1.071; p=0.001) and whether return of spontaneous circulation was achieved (HR, 0.317; 95% CI, 0.127-0.787; p=0.013). Low-flow time was defined as the time from the start of cardiopulmonary resuscitation to the completion of ECMO cannula insertion.

No statistically significant difference in in-hospital mortality was observed between the surgical and percutaneous groups. However, regardless of the chosen cannulation strategy, reducing ECMO cannulation time was beneficial, as a shorter low-flow time was associated with significant benefits in terms of survival.

Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.

Fulminant myocarditis is an acute diffuse inflammatory disease of myocardium. It is characterized by acute onset, rapid progress and high risk of death. Its pathogenesis involves excessive immune activation of the innate immune system and formation of inflammatory storm. According to China's practical experience, the adoption of the "life support-based comprehensive treatment regimen" (with mechanical circulation support and immunomodulation therapy as the core) can significantly improve the survival rate and long-term prognosis. Special emphasis is placed on very early identification,very early diagnosis,very early prediction and very early treatment.

In selected cases of cardiogenic shock, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is combined with trans valvular micro axial flow pumps (ECMELLA). Observational studies indicate that ECMELLA may reduce mortality but exposing the patient to two advanced mechanical support devices may affect the early inflammatory response. We aimed to explore inflammatory biomarkers in a porcine cardiogenic shock model managed with V-A ECMO or ECMELLA.

Fourteen landrace pigs had acute myocardial infarction-induced cardiogenic shock with minimal arterial pulsatility by microsphere embolization and were afterwards managed 1:1 with either V-A ECMO or ECMELLA for 4 h. Serial blood samples were drawn hourly and analyzed for serum concentrations of interleukin 6 (IL-6), IL-8, tumor necrosis factor alpha, and serum amyloid A (SAA).

An increase in IL-6, IL-8, and SAA levels was observed during the experiment for both groups. At 2-4 h of support, IL-6 levels were higher in ECMELLA compared to V-A ECMO animals (difference: 1416 pg/ml, 1278 pg/ml, and 1030 pg/ml). SAA levels were higher in ECMELLA animals after 3 and 4 h of support (difference: 401 ng/ml and 524 ng/ml) and a significant treatment-by-time effect of ECMELLA on SAA was identified (p = 0.04). No statistical significant between-group differences were observed in carotid artery blood flow, urine output, and lactate levels.

Left ventricular unloading with Impella during V-A ECMO resulted in a more extensive inflammatory reaction despite similar end-organ perfusion.

Background: Post-cardiotomy cardiogenic shock (PCCS), which is defined as severe low cardiac output syndrome after cardiac surgery, has a mortality rate of up to 90%. No study has yet been performed to compare patients with PCCS treated by conservative means to patients receiving additional mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (ECMO). Methods: A single-center retrospective analysis from January 2018 to June 2022 was performed. Results: Out of 7028 patients who underwent cardiac surgery during this time period, 220 patients (3%) developed PCCS. The patients were stratified according to their severity of shock based on the Stage Classification Expert Consensus (SCAI) group. Known risk factors for shock-related mortality, including the vasoactive-inotropic score (VIS) and plasma lactate levels, were assessed at structured intervals. In patients treated additionally with ECMO (n = 73), the in-hospital mortality rate was 60%, compared to an in-hospital mortality rate of 85% in patients treated by conservative means (non-ECMO; n = 52). In 18/73 (25%) ECMO patients, the plasma lactate level normalized within 48 h, compared to 2/52 (4%) in non-ECMO patients. The morbidity of non-ECMO patients compared to ECMO patients included a need for dialysis (42% vs. 60%), myocardial infarction (19% vs. 27%), and cerebrovascular accident (17% vs. 12%). Conclusions: In conclusion, the additional use of ECMO in PCCS holds promise for enhancing outcomes in these critically ill patients, more rapid improvement of end-organ perfusion, and the normalization of plasma lactate levels.

The impact of mechanical ventilation on the survival of patients supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) due to severe acute respiratory distress syndrome (ARDS) remains still a focus of research.

Recent guidelines, randomized trials, and registry data underscore the importance of lung-protective ventilation during respiratory and cardiac support on ECMO.

This approach includes decreasing mechanical power delivery by reducing tidal volume and driving pressure as much as possible, using low or very low respiratory rate, and a personalized approach to positive-end expiratory pressure (PEEP) setting. Notably, the use of ECMO in awake and spontaneously breathing patients is increasing, especially as a bridging strategy to lung transplantation. During respiratory support in V-V ECMO, native lung function is of highest importance and adjustments of blood flow on ECMO, or ventilator settings significantly impact the gas exchange. These interactions are more complex in veno-arterial (V-A) ECMO configuration and cardiac support. The fraction on delivered oxygen in the sweep gas and sweep gas flow rate, blood flow per minute, and oxygenator efficiency have an impact on gas exchange on device side. On the patient side, native cardiac output, native lung function, carbon dioxide production (VCO2), and oxygen consumption (VO2) play a role. Avoiding pulmonary oedema includes left ventricle (LV) distension monitoring and prevention, pulse pressure >10 mm Hg and aortic valve opening assessment, higher PEEP adjustment, use of vasodilators, ECMO flow adjustment according to the ejection fraction, moderate use of inotropes, diuretics, or venting strategies as indicated and according to local expertise and resources.

Understanding the physiological principles of gas exchange during cardiac support on femoro-femoral V-A ECMO configuration and the interactions with native gas exchange and haemodynamics are essential for the safe applications of these techniques in clinical practice. Proning during ECMO remains to be discussed until further data is available from prospective, randomized trials implementing individualized PEEP titration during proning.

Currently, use of mechanical circulatory support (MCS) in non-ischaemic cardiogenic shock (CS) is predominantly guided by shock-specific markers, and not by markers of cardiac function. We hypothesise that left ventricular ejection fraction (LVEF) can identify patients with a higher likelihood to benefit from MCS and thus help to optimise their expected benefit.

Patients with non-ischaemic CS and available data on LVEF from 16 tertiary-care centres in five countries were analysed. Cox regression models were fitted to evaluate the association between LVEF and mortality, as well as the interaction between LVEF, MCS use and mortality.

N = 807 patients were analysed: mean age 63 [interquartile range (IQR) 51.5-72.0] years, 601 (74.5%) male, lactate 4.9 (IQR 2.6-8.5) mmol/l, LVEF 20 (IQR 15-30) %. Lower LVEF was more frequent amongst patients with more severe CS, and MCS was more likely used in patients with lower LVEF. There was no association between LVEF and 30-day mortality risk in the overall study cohort. However, there was a significant interaction between MCS use and LVEF, indicating a lower 30-day mortality risk with MCS use in patients with LVEF ≤ 20% (hazard ratio 0.72, 95% confidence interval 0.51-1.02 for LVEF ≤ 20% vs. hazard ratio 1.31, 95% confidence interval 0.85-2.01 for LVEF > 20%, interaction-p = 0.017).

This retrospective study may indicate a lower mortality risk with MCS use only in patients with severely reduced LVEF. This may propose the inclusion of LVEF as an adjunctive parameter for MCS decision-making in non-ischaemic CS, aiming to optimise the benefit-risk ratio.

The importance of temporary mechanical circulatory support for treating acute heart failure with cardiogenic shock is increasingly recognized, and Impella (Abiomed, Danvers, MA, USA) has received particular attention in this regard. Impella is an axial flow left ventricular assist device (LVAD) built into the tip of a catheter. It is inserted via a peripheral artery and implanted into the left ventricle. Although the morphology of Impella is different from a typical LVAD, it has similar actions and effects as an LVAD in terms of left ventricular drainage and aortic blood delivery. Impella increases mean arterial pressure (MAP) and systemic blood flow, thereby improving peripheral organ perfusion and promoting recovery from multiple organ failure. In addition, left ventricular unloading with increased MAP increases coronary perfusion and decreases myocardial oxygen demand, thereby promoting myocardial recovery. Impella is also useful as a mechanical vent of the left ventricle in patients supported with veno-arterial extracorporeal membrane oxygenation. Indications for Impella include emergency use for cardiogenic shock and non-emergent use during high-risk percutaneous coronary intervention and ventricular tachycardia ablation. Its intended uses for cardiogenic shock include bridge to recovery, durable device, heart transplantation, and heart surgery. Prophylactic use of Impella in high-risk patients undergoing open heart surgery to prevent postcardiotomy cardiogenic shock is also gaining attention. While there have been many case reports and retrospective studies on the benefits of Impella, there is little evidence based on sufficiently large randomized controlled trials (RCTs). Currently, several RCTs are now ongoing, which are critical to determine when, for whom, and how these devices should be used. In this review, we summarize the principles, physiology, indications, and complications of the Impella support and discuss current issues and future expectations for the device.