The prognosis in patients with acute myocardial infarction-related cardiogenic shock (AMI-CS) receiving veno-arterial extracorporeal life support (VA-ECLS) and Impella ( ie , ECPELLA) support remains unsatisfactory. The...The prognosis in patients with acute myocardial infarction-related cardiogenic shock (AMI-CS) receiving veno-arterial extracorporeal life support (VA-ECLS) and Impella ( ie , ECPELLA) support remains unsatisfactory. The difference in therapeutic strategy and mortality between left ventricular assist device (LVAD) and non-LVAD centers remains unknown, especially in Japan. Patients with AMI-CS who received Impella support between 2020 and 2023 were prospectively registered in the Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD). The difference in 30 day mortality in patients receiving ECPELLA support between LVAD and non-LVAD centers was retrospectively investigated. A total of 1,549 patients (median 69 years; LVAD center 21.1%) were included. The prevalence of Impella upgrade and LVAD implantation was significantly higher in LVAD center than non-LVAD center. The 30 day mortality was lower in LVAD center than non-LVAD center (45.5% vs . 54.5%, p = 0.002). Multivariable analysis demonstrated that LVAD center and Impella upgrade were independent predictors for lower 30 day mortality with adjusted hazard ratios of 0.791 (95% confidence interval: 0.658-0.953, p = 0.013) and 0.483 (95% confidence interval: 0.339-0.690, p < 0.001), respectively, instead of LVAD implantation. Impella upgrade was more frequent in LVAD center and associated with a lower 30 day mortality among patients with AMI-CS receiving ECPELLA support.
Coveliers J, Gasparotti E, Vignali E
… +21 more, Meani P, Mazzoli M, Kowalewski M, Huizinga E, Gutta K, Piccirillo G, Huberts W, Moradi H, Di Mauro M, Holtackers RJ, de Jong M, Gelsomino S, Paparella D, Körver E, Doddema A, Kawczinski M, Heuts S, Bidar E, Haxhiademi D, Celi S, Lorusso R
Axillary and subclavian artery cannulation for veno-arterial extracorporeal membrane oxygenation (V-A ECMO) offers clinical advantages but introduces complex flow dynamics within the aortic arch. This study employed pati...Axillary and subclavian artery cannulation for veno-arterial extracorporeal membrane oxygenation (V-A ECMO) offers clinical advantages but introduces complex flow dynamics within the aortic arch. This study employed patient-specific computational fluid dynamics (CFD) models derived from 10 computed tomography (CT)-based geometries to simulate ECMO flow via either the right axillary artery or left axillary artery access under varying levels of cardiac dysfunction. Three distinct flow behaviors were observed-descending-directed, arch-split, and retrograde aortic valve (AV)-directed patterns-depending on access site, support level, and aortic geometry. Right axillary artery access more frequently resulted in retrograde flow, particularly in type III arch configurations. In contrast, left axillary artery cannulation promoted antegrade or arch-split flow, independent of arch morphology. These findings suggest that left axillary artery access may provide more favorable antegrade flow hemodynamics in V-A ECMO, particularly when native cardiac output is impaired. Computational fluid dynamics modeling offers valuable insights to guide individualized cannulation strategies based on patient anatomy and cardiac function.
During extracorporeal membrane oxygenation (ECMO) management, early recognition and intervention are essential in cases of membrane oxygenator (MO) oxygenation failure. However, because the MO oxygen transfer (O2 transfe...During extracorporeal membrane oxygenation (ECMO) management, early recognition and intervention are essential in cases of membrane oxygenator (MO) oxygenation failure. However, because the MO oxygen transfer (O2 transfer) capacity is influenced by various factors, clear evaluation criteria are lacking. Theoretical O2 transfer values provided by manufacturers are commonly used to assess MO performance; however, these values are presented only under standardized conditions. In this study, to develop an O2 transfer model for real-world ECMO settings, we conducted perfusion experiments using bovine blood under various venous blood compositions (hemoglobin concentration and oxygen saturation) and operational conditions (blood flow and fraction of delivered oxygen). Although substantial variability was observed in the relationships between O2 transfer and individual parameters, partial correlation analysis revealed significant associations with all factors, underscoring the need to incorporate them into the model. A multilayer feedforward neural network was employed to construct the model, achieving a high coefficient of determination (R2 = 0.992), demonstrating excellent predictive performance. The proposed O2 transfer model provides a framework for evaluating the oxygenation performance of MO under diverse ECMO conditions. By enabling comparison with real-time clinical data, it has the potential to support clinical decision-making and enhance the safety of ECMO management.
Aortic root thrombosis is a rare but potentially fatal complication associated with left ventricular assist device usage, potentially causing myocardial infarction and right heart failure. A patient with aortic root thro...Aortic root thrombosis is a rare but potentially fatal complication associated with left ventricular assist device usage, potentially causing myocardial infarction and right heart failure. A patient with aortic root thrombosis causing left main trunk occlusion early following HeartMate 3 implantation was successfully treated with surgical thrombectomy and a novel outflow graft-aortic root bypass. A 59 year old man with dilated cardiomyopathy and deteriorating heart failure underwent HeartMate 3 implantation and aortic valve repair for advanced circulatory support. Chest pain and reduced left ventricular assist device flow were noted on postoperative day 6. Left coronary cusp thrombosis occluded the left main trunk, causing myocardial infarction. Following emergency percutaneous coronary intervention, surgical thrombectomy was performed, accompanied by an outflow graft-aortic root bypass using a saphenous vein graft to relieve blood stasis in the aortic root for recurrence prevention. Postoperative computed tomography indicated graft patency and no thrombus recurrence. Computational fluid dynamics analysis showed altered flow velocity and wall shear stress within the aortic root, suggesting thrombosis prevention by the bypass. This case highlights a potential role of outflow graft-aortic bypass for recurrent aortic root thrombosis prevention. Additional studies are required to assess effects on clinical outcomes.
Shear-induced platelet activation and receptor shedding in mechanical circulatory support (MCS) paradoxically increase risks of thrombosis and bleeding. Although flow cytometry commonly assesses platelet activation and r...Shear-induced platelet activation and receptor shedding in mechanical circulatory support (MCS) paradoxically increase risks of thrombosis and bleeding. Although flow cytometry commonly assesses platelet activation and receptor expression, correlations with structural changes remain poorly defined. Recent studies emphasize the role of the marginal band (MB) in platelet morphological transitions during activation. This study investigated MB alteration in shear-induced activated platelets and its relationship with flow cytometric markers. Human blood was circulated in a circulatory loop with an MCS device for 4 hours. Under three operating conditions from 75 to 350 mm Hg pressure head, platelet activation (PAC-1 and P-selectin) and glycoprotein (GP) receptor shedding (GPIbα, GPVI, GPIIb/IIIa) were quantified by flow cytometry, and the MB collapse state was microscopically examined and classified. Results demonstrated that platelet activation, receptor shedding, and MB collapse progressively increased with increasing pressure head in the loop. Marginal band collapse correlated strongly with platelet activation, but less with platelet receptor shedding. Marginal band collapse varied significantly among the population of activated platelets, highlighting the complex, heterogeneous response of platelets to shear stresses generated in the loop. The study suggested that the MB collapse can be used as an effective assay to examine platelet activation caused by MCS devices.
The Extracorporeal Life Support Organization (ELSO) Registry is used by a variety of stakeholders to improve patient and institutional care quality, support research and device regulation, monitor practice patterns, and...The Extracorporeal Life Support Organization (ELSO) Registry is used by a variety of stakeholders to improve patient and institutional care quality, support research and device regulation, monitor practice patterns, and share best practices. To achieve these goals, Registry data must be accurate and reliable. In this article, we review the process of ELSO Registry data collection, assess data completeness and integrity, and report on the current status of the data. While accuracy is generally high, it can vary, leaving room for further improvement. Understanding the quality of the data is essential for using it effectively.
International guidelines for the nutrition management of critically ill adults do not sufficiently cover the unique challenges and considerations of patients receiving extracorporeal membrane oxygenation (ECMO). The aim...International guidelines for the nutrition management of critically ill adults do not sufficiently cover the unique challenges and considerations of patients receiving extracorporeal membrane oxygenation (ECMO). The aim of the current guideline is to assess the literature informing nutrition provision and practice for patients receiving ECMO and provide clinicians with consensus-based recommendations to inform clinical practice. A group of international experts was convened by the Extracorporeal Life Support Organization (ELSO) to systematically develop consensus-based recommendations for nutrition therapy. Questions of interest were developed by the authors based on those included in guideline recommendations for general critically ill patients on key clinical areas of nutrition provision and practice during critical illness, but specific to the context of patients receiving ECMO. Following question development, a systematic review of the literature was undertaken, recommendations were developed accordingly, and blind voting was undertaken to determine consensus. Study quality was assessed using the National Institute for Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. A total of 31 publications informed the recommendations with no randomized controlled trials found. Sixteen consensus-based recommendations were formulated for 10 clinical questions, of which 11 reached "strong consensus" (100%) and five "consensus" (87.5%). A total of 26 studies were eligible for quality assessment with 24 (92.3%) rated "fair," 1 (3.8%) rated "good," and 1 (3.8%) rated "poor." There is limited high-level evidence to inform nutrition practice in adult patients receiving ECMO. However, these consensus recommendations have been developed using the available observational data, relevant studies of nutrition in general critically ill patients, and the clinical expertise of those working in high-volume ECMO centers and will help to guide nutrition practices in this patient group.
Ultrasound has become indispensable in the management of patients supported with extracorporeal membrane oxygenation (ECMO), enabling rapid diagnosis, procedural guidance, physiologic monitoring, and informed decision-ma...Ultrasound has become indispensable in the management of patients supported with extracorporeal membrane oxygenation (ECMO), enabling rapid diagnosis, procedural guidance, physiologic monitoring, and informed decision-making across the entire ECMO continuum. This review, conducted under the auspices of the Extracorporeal Life Support Organization (ELSO), provides evidence-based recommendations for the use of ultrasound in adult, pediatric, and neonatal ECMO patients. An international, multidisciplinary panel of experts with dual expertise in ECMO and ultrasound, representing all ELSO chapters, convened to define the scope and structure of the review. A comprehensive literature review identified 133 relevant publications informing recommendations. The review addresses training and competency requirements, choice of ultrasound modalities, and the role of ultrasound before ECMO initiation, during cannulation, throughout ECMO support, for troubleshooting complications, and during ECMO weaning and post-decannulation care. Pre-ECMO ultrasound is emphasized for assessment of cardiopulmonary function, vascular anatomy, and identification of contraindications or reversible conditions. Real-time ultrasound guidance is recommended for cannulation to reduce complications and confirm optimal cannula positioning. During ECMO, echocardiography and extracardiac ultrasound are central to monitoring cardiac function, cannula position, ventricular loading conditions, pulmonary pathology, neurological complications, and vascular integrity. Ultrasound-based strategies for diagnosing hypoxemia, recirculation, tamponade, ventricular distension, and limb ischemia are detailed. Finally, ultrasound plays a critical role in assessing readiness for ECMO liberation and identifying post-ECMO complications. This review highlights the pervasive role of ultrasound as a core competency in ECMO care and provides a practical framework to support safe, effective, and standardized ultrasound use across diverse ECMO programs worldwide.
Use of veno-venous (VV) extracorporeal membrane oxygenation (ECMO) to manage pediatric refractory respiratory failure has significantly increased in the last decade, however, when severe cardiac dysfunction develops or g...Use of veno-venous (VV) extracorporeal membrane oxygenation (ECMO) to manage pediatric refractory respiratory failure has significantly increased in the last decade, however, when severe cardiac dysfunction develops or gas exchange remains impaired, conversion to other forms of bypass becomes essential. This retrospective study aims to evaluate the incidence, outcomes, and predictive factors for VV ECMO conversion in pediatric patients with refractory respiratory failure. Among the 5,162 pediatric patients in the Extracorporeal Life Support Organization (ELSO) Registry received VV ECMO between 2014 and 2024; among these, 421 (8.1%) were converted to veno-arterial (VA) or alternative configurations. The conversion group reported significantly higher in-hospital mortality (51.1% vs. 26.7%, p < 0.001) and higher incidence of complications during ECMO. Both the duration of ECMO support (13 [interquartile range {IQR}: 5; 27] vs. 8 [IQR: 4; 15] days; p < 0.001) and the duration of hospital stay (39 [18-73] vs . 32 [17-57] days, p = 0.007) were significantly longer in the conversion group. Higher levels of pre-ECMO lactate (odds ratio [OR]: 1.056 [95% confidence interval {CI}: 0.999-1.112], p < 0.042) were associated with a higher risk of conversion. This study suggests that the correct selection of the ECMO mode may improve survival and that VV ECMO should not be considered in patients presenting before ECMO deployment both low mean arterial pressure and high lactate levels.
This study aimed to evaluate the feasibility and safety of a novel percutaneous left ventricular assist device CorVad 6.0, for mechanical circulatory support in an ovine model, focusing on device performance, hemocompati...This study aimed to evaluate the feasibility and safety of a novel percutaneous left ventricular assist device CorVad 6.0, for mechanical circulatory support in an ovine model, focusing on device performance, hemocompatibility, and end-organ effects. The CorVad 6.0, which is a microaxial flow pump incorporating an integrated axial-flux motor, was implanted in six healthy sheep via descending aortic access. Animals were supported for 4 weeks, with pump speeds titrated to maintain flows of 1.5-5.0 L/min. All six animals survived the 4 week study period. The CorVad 6.0 was successfully implanted in all subjects with no device-related complications, demonstrating stable operation and a predictable flow response to speed changes. Key hematological and biochemical parameters, including plasma-free hemoglobin, remained within acceptable ranges throughout the study, showing no evidence of significant hemolysis or end-organ dysfunction. Macroscopic and histological analyses of the heart, liver, kidneys, and brain revealed no device-related pathological abnormalities. The CorVad 6.0 demonstrates stable hemodynamic performance and a favorable biocompatibility during a 4 week implantation period. Further study investigating chronic heart failure modes is needed.
The Fontan circulation is a palliative treatment for univentricular heart disease but is prone to progressive hemodynamic failure. To address this, a novel cavopulmonary assist device (CPAD) with dual inlets from the sup...The Fontan circulation is a palliative treatment for univentricular heart disease but is prone to progressive hemodynamic failure. To address this, a novel cavopulmonary assist device (CPAD) with dual inlets from the superior and inferior caval veins was developed. This study examines how varying inflow ratios (IRs) affect the CPAD's hydraulic performance, hemocompatibility, and flow estimation accuracy. Hydraulic performance, represented by the pressure head-flow (H-Q) characteristics, was experimentally and numerically assessed at different IRs. Hemolysis was evaluated experimentally at the nominal operating point (4 L/min, 2,500 RPM) for IRs of 1:1 and 1:3 (n = 5). Additionally, hemocompatibility-related metrics were determined numerically. Furthermore, the robustness of conventional flow estimation methods, based on motor current, pump speed, and viscosity, under varying IRs was examined. In vitro and in silico results indicated low variations in both hydraulic performance (ΔH < 2.2 mm Hg) and hemolysis(22.4% in measured Normalized Index of Hemolysis [NIH]; 4.9% in predicted damage index [DI]) across all investigated IRs. The flow estimation model based on motor current, rotational speed, and fluid viscosity showed high accuracy regardless of the IR, with root mean square error (RMSE) less than 0.148 L/min and R² greater than 0.99. The analyzed double-inflow CPAD performed reliably across the investigated IRs, supporting its suitability for a broad patient population and enabling precise flow monitoring.
The Impella 5.5 is a large-bore transaortic microaxial flow pump used to treat patients with cardiogenic shock (CS). We sought to assess the hemodynamic and clinical response to Impella 5.5 in patients with CS and identi...The Impella 5.5 is a large-bore transaortic microaxial flow pump used to treat patients with cardiogenic shock (CS). We sought to assess the hemodynamic and clinical response to Impella 5.5 in patients with CS and identify predictors of clinical deterioration. We reviewed 265 patients who underwent Impella 5.5 implantation from 2020 to 2024 at two institutions to identify patients in CS. Patients with preoperative extracorporeal life support (ECLS) were excluded and a total of 177 patients made up the final study cohort. Fifty patients (28%) deteriorated while on support and needed escalation to ECLS and/or died in-hospital, while 127 (72%) were successfully bridged to heart replacement therapy (HRT) or discharged without need for escalation of device support. Creatinine, lactate, white blood cell count, central venous pressure, and tricuspid regurgitation (TR) severity were all significantly higher in those with clinical deterioration, while pulmonary artery pulsatility index (PAPi) was lower. Rates of stroke, renal failure, and tracheostomy were significantly higher in those who deteriorated. After adjusting for age and sex, both TR and PAPi <2.5 were associated with clinical deterioration. Overall outcomes with Impella 5.5 in CS patients are encouraging; poor baseline right ventricular function appears to be a predictor of worse outcomes with Impella 5.5 in this population.
Patients with advanced heart failure or cardiogenic shock often require a mechanical circulatory support device (MCSD) before heart transplantation (HT). While extracorporeal membrane oxygenation (ECMO) is commonly used...Patients with advanced heart failure or cardiogenic shock often require a mechanical circulatory support device (MCSD) before heart transplantation (HT). While extracorporeal membrane oxygenation (ECMO) is commonly used for emergent stabilization, transitioning to alternative MCSDs may optimize patients before transplant. Prior studies suggest worse outcomes with ECMO alone. We examined post-HT outcomes in patients bridged from ECMO to other MCSDs. We used the United Network for Organ Sharing (UNOS)/Organ Procurement & Transplantation Network (OPTN) database to identify adults (age ≥18) undergoing HT between 2018 and 2024 who required ECMO at listing. Patients were grouped as ECMO only or ECMO transitioned to left ventricular assist device (LVAD), right ventricular assist device (RVAD), biventricular assist device (BiVAD), or total artificial heart (TAH). Survival was assessed by Kaplan-Meier curves and Cox regression models; outcomes were compared across groups. Of 749 patients, 527 (70%) were supported with ECMO alone. Survival at 30 days, 1 year, and 5 years was similar between ECMO-only and ECMO-to-MCSD (p = 0.46) and across MCSD subtypes (p = 0.96). Right ventricular assist device patients had lower 1 and 5 year survival than ECMO-only (p = 0.004). Rates of rejection, stroke, dialysis, and pacemaker use were similar. Hospital stay was shorter in ECMO-to-MCSD (p = 0.019). Bridging from ECMO to HT using alternative MCSDs is not associated with worse survival or clinical outcomes. Transitioning may offer comparable results with reduced hospital stays.
We describe an innovative application of a modified three-arm veno-venous bypass (VVB) in the management of a complex case of recurrent renal cell carcinoma (RCC) invading the inferior vena cava (IVC) and left renal vein...We describe an innovative application of a modified three-arm veno-venous bypass (VVB) in the management of a complex case of recurrent renal cell carcinoma (RCC) invading the inferior vena cava (IVC) and left renal vein confluence. The patient, with a solitary kidney following right nephrectomy, underwent radical tumor resection and IVC reconstruction. To preserve renal function and minimize ischemic injury, we employed an extracorporeal circuit traditionally used in liver transplantation, adapting it to include an additional cannula in the left renal vein. This configuration allowed continuous renal venous drainage during IVC clamping, limiting kidney warm ischemia to only 14 minutes. The extracorporeal circuit included jugular and femoral venous drainage limbs connected to a centrifugal pump and a third limb providing direct renal outflow, effectively maintaining hemodynamic stability and renal perfusion. Postoperative recovery was uneventful, with transient minimal creatinine elevation and no acute kidney injury. This case demonstrates the versatility of extracorporeal venous bypass circuits in complex onco-vascular surgery and highlights the potential for broader applications of organ support technologies in preserving organ function during major vascular reconstruction. The proposed configuration represents a valuable adjunct in surgeries involving solitary kidneys and prolonged caval occlusion, bridging concepts from transplant and extracorporeal support domains.
This study compared the incidence of intracranial hemorrhage (ICH) among three previously identified acute respiratory distress syndrome (ARDS) subphenotypes: fibrotic, dry, and wet. This retrospective, multicenter obser...This study compared the incidence of intracranial hemorrhage (ICH) among three previously identified acute respiratory distress syndrome (ARDS) subphenotypes: fibrotic, dry, and wet. This retrospective, multicenter observational study used a Japanese database of adult patients with severe ARDS supported with venovenous extracorporeal membrane oxygenation (VV ECMO). The Fine-Gray competing risk models were applied with inverse probability of treatment weighting (IPTW) to evaluate the impact of ARDS subphenotypes on ICH incidence. Of 536 patients included in the analysis, 185 (34.5%) were classified as fibrotic, 185 (34.5%) as dry, and 166 (31.0%) as wet. Intracranial hemorrhage occurred in 3.7% (20/536) of patients during VV ECMO support and was associated with significantly higher mortality compared with patients without ICH (65.0% [13/20] vs. 27.5% [142/516]; p < 0.001). Intracranial hemorrhage incidence was 8.7% (16/185), 0.5% (1/185), and 1.8% (3/166) in the fibrotic, dry, and wet groups, respectively, with a significantly higher incidence in the fibrotic group (p < 0.001). The fibrotic type was independently associated with a higher ICH risk compared with the other two types (hazard ratio: 4.33, 95% confidence interval: 1.47-12.69; p = 0.015). Severe ARDS cases classified as fibrotic had a significantly higher ICH risk during VV ECMO, highlighting the need for increased vigilance in this subgroup.
Vajter J, Garaj M, Holubova G
… +11 more, Spisak F, Laitnerova L, Petrovicova KA, Mikryukova A, Jonas J, Novysedlak R, Vachtenheim J, Martin AK, Lischke R, Vymazal T, Durila M
Extracorporeal membrane oxygenation (ECMO) represents an established modality of intraoperative circulatory and respiratory support during lung transplantation (LTx). Systemic anticoagulation with unfractionated heparin...Extracorporeal membrane oxygenation (ECMO) represents an established modality of intraoperative circulatory and respiratory support during lung transplantation (LTx). Systemic anticoagulation with unfractionated heparin (UFH) remains essential to prevent circuit thrombosis; however, the optimal monitoring strategy during this procedure remains uncertain. Conventional assays, including antifactor Xa activity (anti-Xa), activated partial thromboplastin time (aPTT), aPTT ratio (aPTTr), and activated clotting time (ACT), demonstrate variable sensitivity and reliability, particularly at low UFH concentrations where ACT is often inadequate. This study aimed to evaluate the interrelationship between standard coagulation monitoring methods and to assess the feasibility of using viscoelastic testing, specifically the ROTEM INTEM/HEPTEM clotting time ratio (I/Hr), as a bedside alternative to ACT. A total of 79 patients undergoing LTx with intraoperative ECMO support were analyzed. Unfractionated heparin was administered in all cases, and coagulation parameters were assessed preoperatively, before ECMO cannulation, and during ECMO support. A strong correlation was observed between I/Hr and anti-Xa, with satisfactory agreement with aPTT and aPTTr. Bland-Altman analysis confirmed narrower limits of agreement for I/Hr-derived versus ACT-derived anti-Xa predictions. These findings support I/Hr as a reliable and practical bedside surrogate for UFH monitoring during ECMO-assisted LTx.
The current study aimed to assess the national practice patterns of extracorporeal membrane oxygenation (ECMO) use during the early posttransplant period. We included patients in the United Network for Organ Sharing (UNO...The current study aimed to assess the national practice patterns of extracorporeal membrane oxygenation (ECMO) use during the early posttransplant period. We included patients in the United Network for Organ Sharing (UNOS) database aged greater than 18 years who underwent lung transplantation (LT) between January 1, 2017 and December 31, 2022 (n = 14,999). The study group was divided based on the need for ECMO at 72 hours after LT, as recorded in the database. We analyzed recipient, donor, and procedure-related variables as potential predictors of need for ECMO. One year survival was the primary outcome variable. The overall incidence of ECMO use after LT was 9% (1,357/14,999), with increasing yearly incidence (6.5%-10.7%). Several recipient variables were independently associated with post-LT ECMO use. Additionally, older donors, donation after circulatory death donors, use of machine perfusion, longer ischemia time, and bilateral LT were additional predictors. Patients with post-LT ECMO use had significantly higher 1 year mortality (30.5% vs . 9%, p < 0.001). It is concluded that post-LT ECMO use was independently associated with worse 1 year mortality. Extracorporeal membrane oxygenation is being increasingly deployed among patients with severe allograft dysfunction. The increase in incidence of post-LT ECMO use appears to be fueled by progressively higher-risk donors and recipients. Patients with post-LT ECMO use continue to experience markedly worse outcomes.