Mechanical circulatory support (MCS) devices are standard therapy for advanced heart failure, but modern systems lack standardized methods for setting critical parameters such as rotational speed and flow rate. We develo...Mechanical circulatory support (MCS) devices are standard therapy for advanced heart failure, but modern systems lack standardized methods for setting critical parameters such as rotational speed and flow rate. We developed an integrated model to support MCS parameter adjustment and provide continuous hemolysis and hemodynamic monitoring. The model combines lumped parameter modeling (LPM) and reduced order modeling (ROM) derived from high-resolution computational fluid dynamics of the device. Sensitivity analysis and Bayesian algorithms were used to ensure efficient model calibration and to identify and quantify the most influential parameters driving model outputs. Retrospective data from clinical use of the magnetically levitated centrifugal extracorporeal ventricular assist device MoyoAssist (magAssist, Suzhou, China) were analyzed. The model efficiently fit clinical data (n = 11) using five initial and two subsequent parameters. It provided key hemodynamic information such as left ventricular elastance, pressure-volume (P-V) loops, and hemolysis risk. The model revealed a relationship between rotational speed and cardiac index (CI), identifying a safe adjustment range with a total cardiac index (CI_total) >2.2 and native cardiac index (CI_heart) >0.25. This demonstrates feasibility for rapid P-V loop and ventricular elastance calculation after deployment, providing a basis for defining target CI values and recommending speed adjustments to optimize MCS use. https://links.lww.com/ASAIO/B889.
Heart failure is a significant complication of chronic intravascular hemolysis, a condition characterized by red blood cells (RBCs) breakdown, leading to the release of acellular hemoglobin (Hb) and its oxidized form, me...Heart failure is a significant complication of chronic intravascular hemolysis, a condition characterized by red blood cells (RBCs) breakdown, leading to the release of acellular hemoglobin (Hb) and its oxidized form, methemoglobin (MetHb), into the bloodstream. Acellular Hb promotes nitric oxide (NO) scavenging, oxidative stress, inflammation, iron overload, and functional tissue impairment. This study investigates the direct impact of Hb and MetHb on cardiomyocyte function by assessing calcium transients, fractional shortening, and reactive oxygen species (ROS) formation. The study also evaluated the effects of polymerized Hb, NO scavenging, and antioxidant therapy using N-acetylcysteine (NAC) on cardiomyocyte contractility. Our results show that acellular Hb and MetHb impair cardiomyocyte function by prolonging calcium transient half-life, reducing contractility, and increasing ROS production. Polymerization of Hb and antioxidant supplementation offered partial protection but did not fully mitigate these effects. Inhibiting NO synthase did not increase Hb toxicity, indicating that NO scavenging is not the sole toxicity pathway. These findings demonstrate that Hb-induced cardiomyocyte dysfunction involves a multifactorial mechanism, including NO scavenging, oxidative stress, and disrupted calcium dynamics. Although Hb polymerization and antioxidants offer limited protection, novel multi-target strategies are essential to address Hb toxicity in hemolytic disorders and the use of Hb-based oxygen carriers.
The drainage cannula in a venoarterial extracorporeal membrane oxygenation (VA ECMO) circuit transfers venous blood from the patient to a pump. However, drainage cannulas are prone to thrombosis, leading to significant m...The drainage cannula in a venoarterial extracorporeal membrane oxygenation (VA ECMO) circuit transfers venous blood from the patient to a pump. However, drainage cannulas are prone to thrombosis, leading to significant morbidity in patients. Therefore, this study aimed to evaluate the effects of cannula size, design, and flow rate on flow dynamics and risk of flow-induced thrombosis in different patient geometries using computational fluid dynamics (CFD). Four cannulas (21 Fr and 23 Fr Bio-Medicus and Maquet models) were modeled in three patient-specific venous vasculatures. These were simulated at 2, 3, 4, and 5 L/min drainage flow rates (N = 48 simulations). To assess potential thrombosis risk, a platelet activation model was implemented along with measurement of prothrombotic flow markers. Increasing drainage flow rates worsened washout rates and increased blood residence times and platelet activation rates. The 21 Fr Bio-Medicus cannula had greater activated platelet distributions and higher tip velocities than the 21 Fr Maquet model. Lastly, patient geometry altered blood residence times, washout rates, and activated platelet distributions, but not flow within the cannulas themselves. These findings will be beneficial for clinicians in their cannula selection and cannulation strategy for VA ECMO, as well as engineers in the development of future drainage cannulas.
Cirrhosis was previously listed in Extracorporeal Life Support Organization (ELSO) guidelines as an absolute contraindication for venovenous extracorporeal membrane oxygenation (VV ECMO) and has since been removed. Minim...Cirrhosis was previously listed in Extracorporeal Life Support Organization (ELSO) guidelines as an absolute contraindication for venovenous extracorporeal membrane oxygenation (VV ECMO) and has since been removed. Minimal data report ECMO outcomes for this population, and thus little guides their ECMO candidacy decisions. We queried the ELSO Registry for all patients with cirrhosis who underwent VV ECMO between January 2014 and August 2024 to characterize outcomes compared with a propensity-matched cohort and to identify predictors of survival. Of 48,267 initial VV ECMO runs, 72 patients had cirrhosis (mean age 52 years, 56% male). Twenty (28%) patients survived to hospital discharge compared with 44% survival in the propensity-matched cohort. There were no statistically significant differences in ECMO complication rates or duration of support. Similarly, there were no statistically significant differences in survival and complication rates between patients with cirrhosis and complicated cirrhosis. Univariate and multivariate regression analyses did not identify reliable predictors of mortality. Overall, ECMO outcomes in patients with cirrhosis are worse than all-comers on ECMO but not substantially different than other broadly accepted ECMO indications such as extracorporeal cardiopulmonary resuscitation (ECPR). Until further data emerge, these data may be helpful to centers considering VV ECMO in patients with cirrhosis.
Acute type A aortic dissection (ATAAD) is a life-threatening cardiovascular emergency. Despite the well-established role of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) after postcardiotomy cardiogenic sho...Acute type A aortic dissection (ATAAD) is a life-threatening cardiovascular emergency. Despite the well-established role of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) after postcardiotomy cardiogenic shock in cardiac surgery patients, its application in the context of ATAAD has been controversial. The goal of this study is to evaluate the role of postcardiotomy ECMO subsequent to ATAAD repair. A meta-analysis of nine retrospective studies approaching this topic was conducted. Finally, a total of 318 patients were analyzed. Despite a successful weaning from ECMO rate of 48.3% (95% confidence interval [CI]: 30.6-66.2), not all of them finally survived, resulting in a higher overall in-hospital mortality of 72.4% (95% CI: 61.9-81.9). Acute kidney injury requiring continuous renal replacement therapy rate was 60.5% (95% CI: 43.9-76.0), neurologic complications rate as a consequence of stroke was 24.4% (95% CI: 13.9-36.3), limb ischemia rate was 7.6% (95% CI: 1.7-16.2) and bleeding requiring reoperation rate was 29.2% (95% CI: 10.3-52.2). We estimated a pooled 6.04 days mean duration on ECMO support (95% CI: 3.88-8.20) and a pooled 24.26 days mean length of stay (95% CI: 18.81-29.71). Concerning medium-term outcomes, a pooled incidence rate of late mortality of 5.8% per 100 person-years (95% CI: 0.8-13.4) was recorded. Despite high mortality and complication rates, postcardiotomy ECMO after ATAAD repair may be reasonable, but it depends on further multicenter research to determine which patients could benefit.
Given a reasonable number of patients with contraindications to heparin, a safe and effective alternative to heparin as a purge fluid following Impella® temporary mechanical circulatory support implantation is desired. H...Given a reasonable number of patients with contraindications to heparin, a safe and effective alternative to heparin as a purge fluid following Impella® temporary mechanical circulatory support implantation is desired. Here, we report the feasibility of a bicarbonate-based purge solution (BBPS) compared with a heparinized purge solution (HPS) without systemic anticoagulation in 43 Impella recipients between 2021 and 2023 at three centers in a single healthcare system. In a retrospective review of 43 consecutive Impella recipients, we compared major cardiovascular events (MACE), 30 day mortality, stroke, bleeding, and pump-adequate function between BBPS and HPS patients. Twenty patients on BBPS and 23 patients on HPS were included. They were supported on Impella 5.0 (n = 2), Impella 5.5 (n = 26), and Impella CP (n = 15) for a median of 7.3 days (interquartile range [IQR], 4.6-13.6). The prevalence of MACE, 30 day mortality, bleeding, stroke, and pump function was similar between groups. In this retrospective study, we found no differences in MACE, mortality at 30 days, stroke, bleeding, or pump function between groups exposed to BBPS and HPS. Bicarbonate-based purge solution seems a feasible and safe option for patients with contraindications to heparin use. Prospective studies are needed to confirm our findings.
Extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation (VA ECMO) is a life-saving intervention for selected patients in refractory cardiac arrest. Given the procedure's...Extracorporeal cardiopulmonary resuscitation (ECPR) using venoarterial extracorporeal membrane oxygenation (VA ECMO) is a life-saving intervention for selected patients in refractory cardiac arrest. Given the procedure's technical complexity and time-critical nature, simulation-based training has become essential to ensure both technical proficiency and effective team coordination. However, current commercial simulators are often prohibitively expensive and lack the capacity to integrate ECMO cannulation into standard advanced life support (ALS) scenarios, limiting their real-world applicability and dissemination. To address this gap, we developed a low-cost, customizable phantom using agar-agar, basic household materials, and repurposed medical components. Our model enables ultrasound-guided vascular access, cannula insertion, and initiation of extracorporeal blood flow. It can be easily embedded within ALS mannequins, allowing seamless integration into high-fidelity ECPR simulations. The phantom realistically reproduces key procedural steps and supports training under the high-stress, time-sensitive conditions typical of ECPR. Its adaptability allows use in both technical workshops and in situ simulations involving multidisciplinary teams. This accessible, eco-friendly solution provides a practical alternative to commercial models, promoting broader implementation of ECPR training programs. It represents a step forward in bridging the gap between theoretical knowledge and hands-on practice in critical care education.
Identifying reliable biomarkers associated with clinical outcomes in patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) is essential. Elevated serum Krebs von de...Identifying reliable biomarkers associated with clinical outcomes in patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) is essential. Elevated serum Krebs von den Lungen-6 (KL-6) has been linked to increased mortality in ARDS; however, its prognostic utility in ECMO remains unclear. This multicenter retrospective cohort study analyzed adult patients with severe ARDS who received veno-venous ECMO in 24 Japanese hospitals between 2012 and 2022. Serum KL-6 was measured within 3 days before or after ECMO initiation. The primary outcome was 90 day in-hospital mortality, and the secondary outcome was successful ECMO liberation. Among 373 patients, 265 (71.0%) survived, and 108 (29.0%) died. In multivariable Cox proportional hazards models using restricted cubic splines, higher KL-6 levels were significantly associated with increased 90 day mortality (p = 0.004), whereas lower KL-6 levels were significantly associated with successful liberation from ECMO (p < 0.001). These findings suggest that serum KL-6 measured around the time of ECMO initiation is associated with mortality and liberation outcomes in patients with, supporting its potential as a biomarker of disease severity.
Extracorporeal membrane oxygenation (ECMO) provides temporary support for patients with severe acute cardiac or respiratory failure. Although thrombotic complications are common during ECMO, the real-time detection and m...Extracorporeal membrane oxygenation (ECMO) provides temporary support for patients with severe acute cardiac or respiratory failure. Although thrombotic complications are common during ECMO, the real-time detection and management of thrombosis-related complications remain challenging. In this study, we introduce a noninvasive approach for detecting thrombi using an acoustic detection technique. The presence of blood clots in the ECMO circuit has been correlated with an increase in the amplitude of the acoustic spectrum <20 Hz. This amplification allows for the prediction of clots in the ECMO circuit using acoustic measurements. The predicted results were compared with visual observations, and the technique achieved a total accuracy of 84%. Hypothesizing that some of the false positives were indicators of clots in the circuitry, the accuracy may be up to 96%. This technique could be integrated with the existing clot detection method to enhance patient outcomes.
Aortic regurgitation (AR) is a well-recognized challenge in patients undergoing left ventricular assist device (LVAD) implantation, as it promotes closed-loop circulation, limits effective unloading, and compromises devi...Aortic regurgitation (AR) is a well-recognized challenge in patients undergoing left ventricular assist device (LVAD) implantation, as it promotes closed-loop circulation, limits effective unloading, and compromises device performance. Conventional surgical strategies, including valve replacement or central coaptation stitches, have limitations. We report the case of a 59 year old man with nonischemic cardiomyopathy who was admitted with worsening heart failure and echocardiographic evidence of severe AR due to central malcoaptation of a structurally normal trileaflet aortic valve, along with severe tricuspid regurgitation. The patient underwent concomitant internal aortic ring annuloplasty, tricuspid valve repair with De Vega annuloplasty, and HeartMate 3 LVAD implantation. Postoperative transesophageal echocardiography showed only trace AR and mild tricuspid regurgitation. Recovery was uneventful, and valve function remained stable at 2 month follow-up. This case highlights the feasibility of internal geometric ring annuloplasty as an effective surgical adjunct for managing AR during LVAD implantation. This technique provides annular stabilization, preserves native leaflet function, and minimizes prosthetic burden, making it a physiologic and potentially durable alternative. In the context of mechanical circulatory support, it may fill an important therapeutic gap and deserves further evaluation in future studies.
We report a unique case of a 45 year old man with biventricular assist device (BiVAD) support who has remained asymptomatic despite a complete absence of native cardiac electrical and mechanical activity for 43 months. T...We report a unique case of a 45 year old man with biventricular assist device (BiVAD) support who has remained asymptomatic despite a complete absence of native cardiac electrical and mechanical activity for 43 months. The patient exhibited persistent asystole with stable hemodynamics, oxygenation, and device flows. Echocardiography confirmed absent contractility and continuously open atrioventricular valves. This case illustrates that BiVAD support can maintain adequate systemic and pulmonary circulation even in the absence of intrinsic cardiac activity, representing the longest reported survival under sustained asystole.
Aortic insufficiency (AI) develops in approximately one-third of patients 3 years after continuous-flow left ventricular assist device (LVAD) implantation. Transcatheter aortic valve replacement (TAVR) has recently emerg...Aortic insufficiency (AI) develops in approximately one-third of patients 3 years after continuous-flow left ventricular assist device (LVAD) implantation. Transcatheter aortic valve replacement (TAVR) has recently emerged as a potential option. However, the use of TAVR in patients with LVADs is limited. There are currently only two transcatheter valves, J-Valve and Trilogy Valve, available under expanded access for aortic regurgitation, particularly for patients with LVAD. This case describes a 47 year old male with destination HeartMate 3 LVAD complicated by methicillin-susceptible Staphylococcus aureus bacteremia and severe AI causing cardiogenic shock. Despite inotropic and pharmacologic support, his course was marked by profound deconditioning and fluctuating renal and hepatic function. After a multidisciplinary review, the patient underwent compassionate use of the Trilogy Valve. Post-procedure, he demonstrated marked functional recovery, improving from maximal assistance to independent ambulation, reaching 1,145 feet during 6 minute walk test, and achieving an Activity Measure Post-Acute Care Basic Mobility score of 24/24. The Trilogy Valve is currently under investigation in the ALIGN-AR studies, but has only been used in LVAD patients under compassionate use in the United States. Ongoing registry data (JENA-VAD) and future research are needed to validate procedural standardization, hemodynamic effects, and rehabilitation potential and outcomes in this high-risk population.
Impella support before continuous-flow left ventricular assist device (LVAD) implantation may injure the aortic valve, potentially accelerating aortic regurgitation (AR) progression, resulting in poor outcomes. A single-...Impella support before continuous-flow left ventricular assist device (LVAD) implantation may injure the aortic valve, potentially accelerating aortic regurgitation (AR) progression, resulting in poor outcomes. A single-center retrospective analysis of 384 patients implanted with durable LVADs between 2011 and 2025 was performed. Patients were separated into prior Impella support (group 1, n = 87) and those without (group 2, n = 297). Outcomes included aortic valve intervention at LVAD implantation, AR prevalence at baseline, within 30 days, and 6 months, and mortality at 30 days and 1 year. Aortic valve intervention occurred in 10.3% of group 1 vs. 5.0% of group 2 (p = 0.071). Group 1 had higher baseline AR (24% vs. 15%, p = 0.041) and more moderate or worse AR at 30 days (3.4% vs. 0.3%, p = 0.041) and 6 months (6.8% vs. 0.6%, p = 0.014). Impella duration did not correlate with aortic valve intervention (median 8 vs. 6 days, p = 0.198). Mortality at 30 days (2% vs. 4%, p = 0.958) and 1 year (7% vs. 13%, p = 0.116) was similar. Impella use before durable LVAD was associated with increased AR progression at 30 days and 6 months. This suggests those with preoperative Impella should have the aortic valve assessed at the time of removal and consider intervention if significant.
Posttransplant lymphoproliferative disorder (PTLD) is the second most common malignancy in thoracic transplant recipients and is associated with poor survival. Accurate risk prediction is essential for prevention and man...Posttransplant lymphoproliferative disorder (PTLD) is the second most common malignancy in thoracic transplant recipients and is associated with poor survival. Accurate risk prediction is essential for prevention and management. Adult (≥18 years) heart, lung, and heart-lung transplant recipients were extracted from the Scientific Registry of Transplant (SRTR) and the United Network of Organ Sharing (UNOS) databases. A total of 160 donor and recipient pretransplant variables, including demographics, laboratory tests, induction therapy, and human leukocyte antigens (HLA), were analyzed. Risk scores were developed using the FasterRisk algorithm and compared with statistical and machine learning models. Among 89,139 thoracic recipients, the model achieved cross-validated areas under the curve of 0.776, 0.711, and 0.689 for 1, 3, and 5 year PTLD risk prediction, respectively. Steroid induction and previous malignancy were associated with an increased PTLD risk. Younger age (18-27 years at 1 year; 18-23 years at 5 years) was also linked to higher risk. In contrast, positive Epstein-Barr virus (EBV) status, heart transplantation (compared with lung or combined heart-lung), African American ethnicity, and basiliximab induction were associated with a lower risk. The proposed risk scores enhance understanding of PTLD risk factors and enable individualized prediction during the first 5 years after thoracic transplantation.
Extracorporeal membrane oxygenation (ECMO) may be a life-saving intervention for patients with respiratory or cardiac failure or cardiac arrest. Storing wet-preprimed ECMO circuits can reduce the time to initiate ECMO, b...Extracorporeal membrane oxygenation (ECMO) may be a life-saving intervention for patients with respiratory or cardiac failure or cardiac arrest. Storing wet-preprimed ECMO circuits can reduce the time to initiate ECMO, but safety concerns remain regarding contamination, plasticization, and oxygenator degradation. A scoping review of the literature was conducted using PubMed, EMBASE, and Cochrane Libraries from inception to March 2025. Eligible studies investigated wet-preprimed ECMO circuits for complications of wet-preprimed ECMO circuits. Thirty-two studies met the inclusion criteria. Twenty-three studies reported the risk of bacterial and plasticizer effects over time. Bacterial contamination occurred earlier during storage but once a sterile circuit had been established, the circuit remained sterile. Plasticizer migration was observed to peak after wet priming and decreased over time. Crystalloid priming reduced leaching compared with protein-based fluids, whereas coated tubing further minimized degradation. Oxygenator integrity decreased over time with crystalloid priming. Impairment of gas exchange and increasing transmembrane resistance with increasing storage time were seen. Wet-preprimed ECMO circuits can be safely stored for up to 30 days if sterility is maintained. Large research gaps exist, including priming fluid choice, plasticization migration risks, oxygenator integrity, and duration of safe storage beyond 30 days.