Jahangiri P, Luo Y, Sjatskig J
… +11 more, Şener YZ, Bunge JJH, Dubois E, Meuwese C, Constantinescu A, van der Boon RMA, Manintveld OC, Leebeek FWG, Kluin J, de Boer RA, Caliskan K
Although the latest generation left ventricular assist device (LVAD) HeartMate 3 carries a lower thromboembolic risk than earlier devices, reoperations for early postoperative bleeding remain common. In an effort to redu...Although the latest generation left ventricular assist device (LVAD) HeartMate 3 carries a lower thromboembolic risk than earlier devices, reoperations for early postoperative bleeding remain common. In an effort to reduce early bleeding, we revised our anticoagulation strategy by delaying early heparin bridging. In this single-center retrospective study, we compared two anticoagulation protocols after HeartMate 3 implantation. Under the old protocol, heparin was initiated 24-48 hours after implantation if chest drain output was acceptable. In May 2022, our protocol was revised to withhold unfractionated heparin for greater than or equal to 48 hours after implantation. The primary efficacy endpoint was early (< 30 days) postoperative bleeding requiring reoperation. The primary safety endpoint was early ischemic stroke. We analyzed 193 consecutive patients (106 old protocol, 87 new). The 30 day cumulative incidence of early bleeding requiring reoperation was lower with the new protocol (42.4% vs. 24.1%, p = 0.006). Stroke incidence did not differ significantly (6.6% vs. 8.0%, p = 0.72). Total hospital stay (28 vs. 24 days, p = 0.04) and intensive care unit (ICU) stay (7 vs. 5 days, p = 0.03) were shorter with the new protocol. Delaying heparin initiation beyond 48 hours after HeartMate 3 implantation was associated with reduced early bleeding-related reoperations and shorter ICU and hospital stays, without a significant increase in stroke risk.
In acute respiratory distress syndrome (ARDS) complicated by acute kidney injury (AKI), severe acidemia may limit implementation of protective ventilation. Continuous renal replacement therapy (CRRT) may improve acid-bas...In acute respiratory distress syndrome (ARDS) complicated by acute kidney injury (AKI), severe acidemia may limit implementation of protective ventilation. Continuous renal replacement therapy (CRRT) may improve acid-base control either by increasing dialysate bicarbonate concentration or by combining CRRT with extracorporeal carbon dioxide removal (ECCO 2 R). We compared these strategies in a randomized experimental model. Twelve anesthetized Landrace pigs underwent surgical induction of anuric AKI followed by protocolized hypoventilation with stepwise tidal volume (Vt) reduction. Animals were assigned to CRRT with very-high bicarbonate dialysate (60 mEq/L) alone or CRRT with high bicarbonate dialysate (40 mEq/L) plus low-flow ECCO 2 R. The primary outcomes were time to vasopressor initiation and the lowest Vt achieved while maintaining arterial pH ≥7.2 during a 12 hour protocol. Both strategies corrected hypercapnic acidemia and enabled substantial Vt reduction, approximately 50% from baseline, without differences between groups at 12 hours ( p = 0.756). Time to vasopressor initiation was likewise similar (hazard ratio [HR] = 0.76, 95% confidence interval [CI] = 0.21-2.71). Cardiac output remained preserved despite increasing vasopressor requirements. In this experimental AKI model, very-high bicarbonate CRRT provided short-term pH control comparable to CRRT plus ECCO 2 R, supporting ultralow-Vt ventilation.
Static controlled hypothermic donor heart transportation (SCTS) has been shown to improve survival and lower rates of severe primary graft dysfunction (PGD) after heart transplantation (HT) as compared to ice. The curren...Static controlled hypothermic donor heart transportation (SCTS) has been shown to improve survival and lower rates of severe primary graft dysfunction (PGD) after heart transplantation (HT) as compared to ice. The current study examined preservation strategy and sex-specific risk of PGD in the GUARDIAN-Heart registry. Adult HT recipients from October 2015 through July 2025 were included. A propensity-matched cohort was fit using nearest-neighbor matching to compare clinical outcomes by sex and preservation method. A total of 1,723 (29% women) HT recipients were included. In the propensity-matched cohort, rates of severe PGD in the SCTS group were comparable to ice despite significantly longer distance traveled and ischemic times in the SCTS group in both men and women. Women-SCTS experienced significantly lower rates of severe right ventricular (RV) dysfunction at 24 hours compared to the women-ICE group (1% vs . 14%, p < 0.001). One year survival was similar between ice and SCTS in men (92% vs . 95%, p = 0.15) and in women (96% vs . 94%, p = 0.54). Despite longer ischemic times and travel distances, the women-SCTS group had similar outcomes to the women-ice (NCT04141605).
Extracorporeal membrane oxygenation (ECMO) supports patients with end-stage heart and lung disease awaiting transplantation. In pulmonary hypertension, veno-arterial ECMO (VA-ECMO) is common but linked to vascular compli...Extracorporeal membrane oxygenation (ECMO) supports patients with end-stage heart and lung disease awaiting transplantation. In pulmonary hypertension, veno-arterial ECMO (VA-ECMO) is common but linked to vascular complications and limited mobility, hindering pre-transplant rehabilitation. To overcome these challenges, we developed the BioArt-Lung (BAL) cannula-a trans-septal, dual-lumen, self-expanding device enabling cardiopulmonary support through single venous access, avoiding groin cannulation. Bench tests compared BAL with three dual-lumen cannulas, assessing pressures and transluminal flow using water and blood analogs at 0° and 120° angulation. Placement feasibility was evaluated on a three-dimensional (3D)-printed heart model, and right atrial unloading was tested via inferior vena cava perfusion. Pressure and flow remained consistent across fluids and angulations ( p = ns). BioArtificial Lung exhibited significantly less admission lumen depression than Avalon 27Fr ( p < 0.0001). Trans-septal insertion was smooth, and complete right atrial unloading occurred at 2 L/min flow. BioArtificial Lung demonstrated effective hemodynamics and feasible trans-septal placement via superior vena cava access. These results support further in vivo studies to assess biocompatibility and long-term outcome.
Cacioli G, Gallone G, Verde A
… +29 more, Tejada E, Konicoff M, Ciabatti M, Marcelli G, Díez-López C, Conti N, Piazza V, Cannata A, Pidello S, Sbaraglia F, Monteagudo Vela M, Spitaleri A, Comisso M, Bruno CF, Lilla Della Monica P, Sánchez-Salado JC, Frea S, Raineri C, Russo CF, Morley-Smith A, Garascia A, Rinaldi M, Baldetti L, Luzi G, González-Costello J, Riesgo Gil F, Tedford RJ, Loforte A, De Ferrari GM
Vasodilator challenge during right heart catheterization (RHC), by improving right ventricular (RV) loading conditions, could provide an assessment of RV functional reserve. We hypothesized that a dynamic evaluation of R...Vasodilator challenge during right heart catheterization (RHC), by improving right ventricular (RV) loading conditions, could provide an assessment of RV functional reserve. We hypothesized that a dynamic evaluation of RV function with sodium nitroprusside (NTP) infusion could enhance conventional risk stratification for post-left ventricular assist device (LVAD) early RV failure (RVF). We performed an observational retrospective multicenter study including consecutive LVAD recipients undergoing vasodilator challenge within 3 months from surgery. We evaluated the association of clinical, echocardiographic, and hemodynamic data at baseline and after NTP infusion with post-LVAD early RVF. Of 160 patients, RVF occurred in 58 (36.3%) and was associated with higher in-hospital mortality (32.8% vs . 3.9%, p < 0.001). Among baseline hemodynamics, pulmonary artery pulsatility index (PAPi) <2 was the single variable associated with RVF ( p = 0.038). In a multivariable model adjusted for in-study outcome predictors, a blunted PAPi response to vasodilator challenge (PAPi increase <2.2) emerged as the strongest independent RVF predictor (odds ratio [OR] = 4.56, 95% confidence interval [CI] = 1.88-11.07, p = 0.001). Patients with a blunted PAPi response had an increased RVF risk both in the baseline PAPi <2 (61.9% vs . 12.5%, p = 0.022) and in the baseline PAPi ≥2 (40.2% vs . 17.5%, p = 0.004) groups. Vasodilator challenge, by unveiling RV functional reserve, could improve patient selection and optimization before LVAD implant.
In extracorporeal therapies such as cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO), the transport of blood through artificial circulation frequently results in the rupture of erythrocytes, rel...In extracorporeal therapies such as cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO), the transport of blood through artificial circulation frequently results in the rupture of erythrocytes, releasing hemoglobin (Hb) into the plasma (fHb), and exhausting the body's supply of the natural fHb scavenger-haptoglobin (Hp). This complication, known as mechanical hemolysis, results in the release of fHb and its downstream heme-containing degradation products and is associated with multi-organ dysfunction and adverse outcomes. Current strategies for mitigating hemolysis in extracorporeal circuits are either resource-intensive or nonspecific. Here, we describe the fabrication and benchtop evaluation of an fHb-adsorbing device intended as an adjunctive, intermittent, time-limited approach to reduce fHb. Human Hp was immobilized onto a cross-linked agarose resin and loaded into a packed-bed device compatible with whole-blood perfusion. Under controlled recirculation conditions, the device demonstrated the ability to capture fHb and attenuate its accumulation relative to control. A regenerative protocol was developed to disrupt the Hp-Hb complexes and restore a substantial fraction of Hp binding activity. These findings support both the feasibility of immobilized Hp for selective fHb capture under benchtop conditions as well as the need for further device optimization and evaluation in more physiologically representative extracorporeal models. https://links.lww.com/ASAIO/B922.
This retrospective single-center study evaluated adults with cardiogenic shock supported with veno-arterial extracorporeal membrane oxygenation (VA ECMO) from 2011 to 2023 to identify predictors of in-hospital mortality...This retrospective single-center study evaluated adults with cardiogenic shock supported with veno-arterial extracorporeal membrane oxygenation (VA ECMO) from 2011 to 2023 to identify predictors of in-hospital mortality among those who survived to decannulation. Continuous and categorical variables were analyzed using Wilcoxon rank-sum test, chi-squared test, or Fisher's exact tests. Poisson regression was used to identify independent predictors of mortality. Of 588 patients who received VA ECMO, 419 (71%) survived to decannulation. Of these, 320 (77%) survived to discharge, and 99 (23%) died post-decannulation. Patients who died were older (66 vs. 60 years; p < 0.001) and more likely to have chronic kidney disease (42% vs. 27%; p = 0.003), hypertension (79% vs. 67%; p = 0.028), and prior stroke (14% vs. 6.6%; p = 0.017). Extracorporeal membrane oxygenation duration was longer (4.9 vs. 3.9 days; p = 0.013), and Impella use was more frequent (24% vs. 16%; p = 0.049). The leading cause of death was withdrawal of care (42%). Age, extracorporeal cardiopulmonary resuscitation (ECPR), and post-cardiotomy shock were the only independent predictors of in-hospital mortality (relative risk [RR], 1.06; 95% confidence interval [CI], 1.01-1.10; p = 0.010). Nearly one in four patients who survived ECMO decannulation died before discharge. Older age, longer time on ECMO, and comorbidities were more prevalent among non-survivors. These findings underscore the need for improved post-decannulation risk stratification.
Decompensated differential carbon dioxide (CO2) removal can occur during spontaneous breathing on peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) when a low right radial arterial partial pressure o...Decompensated differential carbon dioxide (CO2) removal can occur during spontaneous breathing on peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) when a low right radial arterial partial pressure of carbon dioxide (PaCO2) prompts sweep gas flow (SGF) reduction, decreasing extracorporeal CO2 removal and shifting the compensatory burden to the native lung. When cardiac output (CO) remains low, this shift may require disproportionately higher alveolar ventilation, manifesting as tachypnea and increased work of breathing. We therefore frame this phenotype as a CO-dependent CO2 "budget" imbalance that is modulated by the aortic mixing point, rather than solely cerebral exposure to CO2-rich retrograde ECMO blood. We outline a pragmatic, non-protocol bedside heuristic anchored to post-membrane pH/PaCO2 targets, using multi-site blood gases to contextualize the mixing point and guide physiologic optimization of preload, ECMO blood flow, and SGF. Treating the loop, rather than isolated right-radial values, may reduce iatrogenic escalation and provide a testable foundation for future mechanistic studies.
Extracorporeal membrane oxygenation (ECMO) provides lifesaving support for patients with cardiopulmonary failure but poses complex ethical challenges that may generate moral distress for clinicians, patients, and familie...Extracorporeal membrane oxygenation (ECMO) provides lifesaving support for patients with cardiopulmonary failure but poses complex ethical challenges that may generate moral distress for clinicians, patients, and families. We convened a multidisciplinary panel of experts in cardiothoracic surgery, critical care, and palliative medicine to identify recurring ethical issues. The panel includes ECMO specialists working in the US, Canada, and the UK. The panel was nominated by organizers of a national critical care meeting. We analyzed four domains of ethical tension: 1) equitable ECMO candidacy decisions; 2) integration of palliative care and clinical ethics; 3) preservation of patient autonomy when institutional or benchmarking pressures influence care; and 4) responding to requests to continue ECMO when there is no exit strategy. Consensus recommendations emphasize transparent, team-based decisions, early involvement of ethics and palliative care, and consistent processes for ongoing review of candidacy and continuation of ECMO. Programs should recognize and mitigate institutional pressures that may undermine patient-centered care. As ECMO use expands, the development of ethical care frameworks is essential to ensure equity, uphold autonomy, and align treatments with patients' goals and values. This work provides a practical, consensus-based guide for addressing the ethical complexities of ECMO in contemporary critical care.
Social determinants of health (SDOH) are increasingly recognized as drivers of critical care outcomes but remain understudied in venoarterial extracorporeal membrane oxygenation (VA ECMO). We examined whether neighborhoo...Social determinants of health (SDOH) are increasingly recognized as drivers of critical care outcomes but remain understudied in venoarterial extracorporeal membrane oxygenation (VA ECMO). We examined whether neighborhood-level SDOH were associated with 30 day post-discharge survival and prolonged length of stay (LOS) among VA ECMO patients. We retrospectively analyzed VA ECMO patients treated at Johns Hopkins Hospital, linking geocoded addresses to 12-digit Federal Information Processing Standards (FIPS) codes, 2022 American Community Survey data, 2023 Area Deprivation Index (ADI), and PolicyMap metrics. The primary outcome was 30 day mortality from discharge; secondary outcome was prolonged LOS (> 38 days, median among survivors). Multivariable logistic regression adjusted for preselected variables. Among 266 VA ECMO patients (median age: 59.50, 59% male), the median ADI percentile was 31.00, and LOS was 20.50 days. At 30 days, non-survivors (n = 133) were older (62 vs. 55 years, p = 0.002) and had higher body mass index (34.7 vs. 25.2, p < 0.001). Prolonged LOS was associated with longer ECMO duration, higher neighborhood insurance coverage, and greater commuting by car. In adjusted models, SDOH were not associated with mortality, but higher insurance coverage remained associated with prolonged LOS. Clinical factors influenced short-term survival, whereas neighborhood-level SDOH may affect discharge. Future studies should evaluate SDOH in long-term recovery. https://links.lww.com/ASAIO/B925.
To determine if immunocompromised (IC) status correlates with higher hospital mortality in acute respiratory distress syndrome (ARDS) patients on extracorporeal membrane oxygenation (ECMO) and the impact of IC type on ou...To determine if immunocompromised (IC) status correlates with higher hospital mortality in acute respiratory distress syndrome (ARDS) patients on extracorporeal membrane oxygenation (ECMO) and the impact of IC type on outcomes. On February 10, 2026, searches were conducted in PubMed, Embase, Cochrane Library, and the International Clinical Trials Registry Platform (ICTRP). Eligible English full-text cohort studies of adults meeting the 2012 Berlin ARDS criteria, including IC versus immunocompetent (ICM) studies and IC-only studies. Study quality was assessed using the Newcastle-Ottawa Scale. Outcomes included primary (hospital mortality) and secondary (ECMO weaning rate, 6 month mortality). Analyses were performed with RevMan/R 4.4.2; risk ratio (RR)/odds ratio (OR) for effect sizes, and Cochrane Q test/I2 for heterogeneity. Seventeen studies (17 retrospective, 2 prospective; 12 IC vs. ICM, 7 IC-only) involving 5,136 patients (1,311 IC, 3,825 ICM) were included. Immunocompromised patients had a lower ECMO weaning rate (RR = 0.77), higher hospital mortality (RR = 1.38), and higher 6 month mortality (RR = 1.31). Subgroup analysis showed: high risk (hematological malignancies, OR = 3.76), moderate risk (autoimmune diseases, OR = 2.50), low risk (solid organ transplantation, OR = 1.40). No significant publication bias. Immunocompromised patients are an independent risk factor for poor ECMO outcomes in ARDS. Outcomes differ by IC type; ECMO may be considered for selected IC patients, especially low-risk subgroups.
Extracorporeal membrane oxygenation (ECMO) can trigger a systemic inflammatory response syndrome (SIRS) with activation of inflammatory, endothelial, and coagulation system pathways. We assessed in a randomized trial whe...Extracorporeal membrane oxygenation (ECMO) can trigger a systemic inflammatory response syndrome (SIRS) with activation of inflammatory, endothelial, and coagulation system pathways. We assessed in a randomized trial whether a) sweep flow nitric oxide (sNO) reduces these responses, b) what the temporal trajectory of these markers post-ECMO commencement is, and c) how serum marker concentrations are associated with survival. Fifty-three patients were randomized (25 sNO, 28 control). Serum levels of inflammatory cytokines (IL-1, IL-6, IL-8, IL-10, TNF-α), complement (C1q, C3, C4, C5a, C9, factor H, factor B), immune regulators (CD40L, P-Selectin), and coagulation factors (PF4, MBL, ADAMTS13) were measured at (t0) and 1, 12, 24 hours post (t1-t3) ECMO initiation. Sweep flow nitric oxide did not alter serum biomarker trajectories. Across sNO and control groups, serum marker concentrations declined from t0 to t1 with variable patterns thereafter, but no consistent ECMO-associated elevation. Elevated IL-6 and IL-8 before and after ECMO commencement were associated with mortality, whereas higher P-Selectin, CD40 Ligand, and PF4 correlated with survival. Sweep flow nitric oxide did not modify markers of inflammation, endothelial, or coagulation activation during ECMO. Evidence of an ECMO-induced cytokine storm was absent, but serum biomarkers predicted mortality in ECMO-supported neonates and children.
Fluid shear stress plays a vital role in regulating renal epithelial cell behavior in vivo. However, conventional static culture systems fail to recapitulate these mechanical cues. To address this limitation, we develope...Fluid shear stress plays a vital role in regulating renal epithelial cell behavior in vivo. However, conventional static culture systems fail to recapitulate these mechanical cues. To address this limitation, we developed a simple two-dimensional (2D) microfluidic device to investigate the effects of shear stress on human proximal tubular cells (hPTCs). We have called this the NephroFlux Device. It was designed using AutoCAD and fabricated with polydimethylsiloxane (PDMS) via soft lithography, then bonded to glass coverslips using oxygen plasma treatment. Scanning electron microscopy (SEM) was used to observe morphological changes in apical structures such as microvilli and primary cilia within the device. Flow exposure within the NephroFlux device significantly improved cell proliferation and surface coverage compared with static conditions. In addition to increased density, cells exposed to flow were characterized by an increased microvillus density and elongated primary cilia. Collectively, these results establish NephroFlux as a practical tool for the application of flow, facilitating investigation of renal mechanobiology and providing a foundation for future applications in disease modeling, nephrotoxicity testing, and artificial organ development.
Ventricular septal rupture (VSR) is a rare but often fatal complication of acute myocardial infarction (AMI), with a high mortality largely driven by resultant cardiogenic shock. Venoarterial extracorporeal membrane oxyg...Ventricular septal rupture (VSR) is a rare but often fatal complication of acute myocardial infarction (AMI), with a high mortality largely driven by resultant cardiogenic shock. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides emergency circulatory support and may improve outcomes. We retrospectively analyzed the Extracorporeal Life Support Organization (ELSO) Registry to identify adults (≥18 years) with post-AMI VSR receiving preoperative VA-ECMO (2000-2025). Clinical characteristics were compared between survivors and nonsurvivors. The primary outcome was in-hospital survival. Among 370 patients, the median age was 66 years, 70% were male, and 66% were in cardiogenic shock at ECMO initiation. Inferior AMI occurred in 56%, and 56% had prior mechanical circulatory support. In-hospital mortality was 68%. Survivors were significantly younger (median 62 vs . 67 years) and had lower rates of pre-ECMO cardiac arrest (7% vs . 21%), tamponade (2% vs . 8%), and renal replacement therapy (21% vs . 37%). Survivors also experienced longer duration of ECMO support and hospital length of stay. While rescuing many patients in post-AMI VSR-related shock, mortality remains high. Identifying predictors of survival and optimizing perioperative management are essential to improve outcomes in this high-risk group.
Differential oxygenation may complicate extracorporeal cardiopulmonary resuscitation (ECPR) either due to the initial pathology or subsequent lung injury. The dual circulation phenomenon inherent to peripheral venoarteri...Differential oxygenation may complicate extracorporeal cardiopulmonary resuscitation (ECPR) either due to the initial pathology or subsequent lung injury. The dual circulation phenomenon inherent to peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) risks poorly oxygenated blood preferentially supplying the cerebral circulation. This may be deleterious to neurological outcomes and survival in this cohort. We describe two novel cases of parallel VV-ECMO support following ECPR, using a dual-lumen bicaval cannula to salvage severe differential hypoxemia. Decannulation of arterial support occurred at 4 and 7 days, respectively, with initial reconfiguration to high-flow VV-ECMO. This unique approach offers an attractive alternative to hybrid VAVECMO and may provide a necessary escalation following successful ECPR to facilitate neuroprotection. https://links.lww.com/ASAIO/B896.