J Extra Corpor Technol
· 2025 Dec · PMID 41405038
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BACKGROUND: Cardioplegia is essential for myocardial protection during cardiac surgery. The COVID-19 pandemic disrupted supply chains, affecting the availability of commercial cardioplegia solutions in Thailand and promp...BACKGROUND: Cardioplegia is essential for myocardial protection during cardiac surgery. The COVID-19 pandemic disrupted supply chains, affecting the availability of commercial cardioplegia solutions in Thailand and prompting institutions to modify their strategies. This study evaluates the distribution, selection, and adaptation of cardioplegia practices among Thai cardiac surgical centers during the pandemic. METHODS: A nationwide survey was conducted in cardiac surgical centers performing ≥100 cases per year. Data on cardioplegia availability, usage, and preferences across different surgeries were collected via direct or telephone interviews with surgeons or perfusionists. Descriptive statistical analyses were applied. RESULTS: St. Thomas-based cardioplegia remained the most widely used (95%), with 77.1% of institutions preparing custom formulations due to supply shortages. Histidine-tryptophan-ketoglutarate (HTK) was the second most used (76%), particularly in aortic and complex congenital surgeries, followed by del Nido cardioplegia (27%), often in modified formulations. Most centers (74%) used two to three cardioplegia solutions. Blood cardioplegia was preferred for coronary artery bypass grafting (89.2%) and valve procedures (78.4%), whereas HTK dominated in aortic (54.1%) and complex congenital surgeries (71.4%). CONCLUSION: Despite the pandemic, St. Thomas-based cardioplegia remained dominant in Thailand, with increasing reliance on HTK and modified del Nido cardioplegia. The widespread use of custom-made cardioplegia highlights the impact of supply chain disruptions. Post-pandemic studies are essential to evaluate long-term adaptations and refine myocardial protection strategies.
Gore K, Linder D, Duque JJM
… +7 more, Wang J, Baguley J, Kolesnikowicz C, Yockelson S, Singh M, Ruiz AA, Nossaman BD
J Extra Corpor Technol
· 2025 Dec · PMID 41405037
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INTRODUCTION: Patients receiving mechanical circulatory support (MCS) risk the development of sepsis. Examining risk factors for the development of sepsis and their relationships to MCS may allow for an improved understa...INTRODUCTION: Patients receiving mechanical circulatory support (MCS) risk the development of sepsis. Examining risk factors for the development of sepsis and their relationships to MCS may allow for an improved understanding of these complications. METHODS: Following IRB approval, patient characteristics, previously reported comorbidities, and the incidence of sepsis were studied in 199 patients who received 244 MCS therapies from January 2017 to October 2023. The clinical variables underwent ensemble machine learning modeling. Significant comorbidities predicting sepsis from the ensemble machine modeling underwent decision-tree analysis. RESULTS: In this study, the incidence of sepsis was 20% (95% CI: 16-26%). Following machine learning modeling, patients with a history of congestive heart failure or a history of previous cardiac surgery were associated with an increased risk for developing sepsis. The c-index statistic for this model was 0.76, with a misclassification rate of 19%. Decision-tree analysis observed that patients without chronic cardiovascular disease but with a history of prior cardiac surgery have a 60.3% (95% CI: 60.1-65.2%) incidence of sepsis during MCS therapy. Patients with a history of chronic cardiovascular disease and with a history of congestive heart failure have an 18.1% (95% CI: 17.2-18.7%) incidence of developing sepsis. CONCLUSION: The incidence of sepsis is high in this patient population. The novel associations of patients who have histories of congestive heart failure or previous cardiac surgery requiring MCS suggest an increased systemic inflammatory state exists that escalates the risk for developing sepsis. Further investigation into these background inflammatory conditions in patients requiring MCS is warranted.
Ratiu A, Linick JA, Oyugi A
… +3 more, Williams J, Wherry K, Klavetter E
J Extra Corpor Technol
· 2025 Dec · PMID 41405036
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BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a powerful, life-prolonging technology, but is resource-intensive. METHODS: This retrospective analysis utilized Medicare Fee-for-Service (FFS) inpatient data (Oc...BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a powerful, life-prolonging technology, but is resource-intensive. METHODS: This retrospective analysis utilized Medicare Fee-for-Service (FFS) inpatient data (October 2019-December 2022) to identify ECMO hospitalizations with continuous FFS coverage. We assessed total payment, costs, length of stay (LOS), and predominant medical severity diagnosis-related group (MS-DRG) and International Classification of Diseases (ICD-10) codes. Outcomes were stratified by DRG code, ICD-10 procedure codes, and ECMO type. Hospital costs were estimated using cost-to-charge ratios from the Centers for Medicare and Medicaid Services with a 3-year lag. RESULTS: Continuous ECMO within MS-DRG 003 discharged between January 1, 2020, and December 31, 2022, were a subset of hospitalizations analyzed. For continuous central (CC) ECMO, mean costs were $287,334, median costs were $223,766, and the standard deviation (SD) was $224,261. Mean payment was $264,021, median was $218,642, and SD was $157,882. For continuous venoarterial (VA) ECMO, mean costs were $245,448, median was $191,363, and SD was $212,822. Mean payment was $241,617, median was $202,199, and SD was $145,456. For continuous venovenous (VV) ECMO, mean costs were $329,111, median was $256,706, and SD was $285,745. Mean payment was $298,141, median was $237,679, and SD was $198,160. The majority of patients (64%) received VA, which was the only ECMO type with a median payment that surpassed median costs. Rural facilities and teaching hospitals had consistently higher mean frequencies among all ECMO claims (CC, VA, VV) from October 2019 to December 2022 compared to their counterparts (Rural: CC = 2.4, VA = 9.3, VV = 4.9; Urban: CC = 1.4, VA = 6.1, VV = 2.2; Teaching: CC = 2.1, VA = 8.6, VV = 3.4; Non-teaching: CC = 0.5, VA = 1.9, VV = 0.7). CONCLUSION: VV ECMO had the highest median costs and payment among the ECMO types. Median payment was less than median hospitalization costs for all types of ECMO, apart from continuous VA ECMO.
Takeichi T, Morimoto Y, Yamada A
… +8 more, Tanaka T, Fujiwara K, Sato M, Toma R, Mitsui K, Sugita T, Yamada H, Gan K
J Extra Corpor Technol
· 2025 Dec · PMID 41405035
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OBJECTIVES: This study aimed to assess whether continuous furosemide administration during cardiopulmonary bypass (CPB) in minimally invasive cardiac surgery (MICS) reduces the incidence of cardiac surgery-associated acu...OBJECTIVES: This study aimed to assess whether continuous furosemide administration during cardiopulmonary bypass (CPB) in minimally invasive cardiac surgery (MICS) reduces the incidence of cardiac surgery-associated acute kidney injury (AKI). METHODS: A total of 100 patients undergoing MICS with CPB were randomly assigned to receive either continuous furosemide infusion or no continuous furosemide during CPB. The primary endpoint was the incidence of AKI. Secondary endpoints included the cardiac surgery-associated neutrophil gelatinase-associated lipocalin (CSA-NGAL) score, urine output within 12 h postoperatively, postoperative furosemide dose requirements, red blood cell transfusion volume, PaO/FiO ratio, duration of mechanical ventilation, length of stay in the intensive care unit (ICU) and hospital, and in-hospital mortality. RESULTS: AKI occurred in 8 patients (16%) in the continuous furosemide group and in 6 patients (12%) in the non-continuous group (relative risk, 0.72; 95% CI, 0.23-2.23). Among the secondary endpoints, urine output within the first 3 h postoperatively and the PaO/FiO ratio were significantly higher in the continuous furosemide group. However, subgroup analyses revealed no significant differences between the two groups. CONCLUSIONS: Continuous furosemide administration during CPB did not effectively reduce the incidence of AKI. However, it was associated with a significant increase in postoperative urine output and an improvement in the PaO/FiO ratio.
J Extra Corpor Technol
· 2025 Dec · PMID 41405034
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INTRODUCTION: Fluid and electrolyte balance is closely managed in extracorporeal membrane oxygenation (ECMO) patients. Neglecting oxygenator-related insensible fluid losses can distort fluid balance and electrolyte level...INTRODUCTION: Fluid and electrolyte balance is closely managed in extracorporeal membrane oxygenation (ECMO) patients. Neglecting oxygenator-related insensible fluid losses can distort fluid balance and electrolyte levels. While ECMO oxygenator insensible losses are reported, they remain undefined for the Medtronic Nautilus oxygenator. Through in vitro analysis of the Nautilus, we quantified insensible water losses while concurrently observing sodium behavior. METHODS: Insensible water losses were determined using a closed circuit. A 12-hour pilot run was conducted to saturate the oxygenator and determine probable water loss rates and sodium accumulation behaviors. Fluid loss and sodium measurements were made at 0, 6, and 12 h. Immediately following the pilot run, three randomly assigned sweep gas rates, 0.5, 1.0, and 1.5 L/min, were evaluated over a 24 h period and replicated in triplicate. The circuit parameters were consistent and controlled for each trial. Data were collected at 0, 12, and 24 h for visualized water loss in the reservoir. After each trial, sterile water was introduced into the circuit via syringe and recorded as replacement volume. Sodium measurements were made for three trials (0.5, 1.0, and 1.5) and collected at 0 and 24 h. RESULTS: Using linear regression analysis, the following insensible water loss equations were produced. Visualized volume: 2.74 mL/h per 1 L/min sweep gas rate or 65.66 mL/day per 1 L/min of sweep gas rate (p < 0.001). Replacement volume: 3.02 mL/h per 1 L/min of sweep gas rate or 72.5 mL/day per 1 L/min of sweep rate (p < 0.001). Sodium accumulation was observed, but not statistically significant due to the small sample size. CONCLUSION: Insensible water loss in the Nautilus ECMO oxygenator increases linearly with sweep gas rate (p < 0.001), leading to sodium accumulation through evaporation. These losses and the associated risk for hypernatremia should be considered when managing a patient's fluid and electrolyte balance on ECMO.
J Extra Corpor Technol
· 2025 Dec · PMID 41405033
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BACKGROUND: Postoperative delirium, regularly seen after cardiac surgery, is challenging. It has significant implications for healthcare resources and significant implications for individual patients and their families....BACKGROUND: Postoperative delirium, regularly seen after cardiac surgery, is challenging. It has significant implications for healthcare resources and significant implications for individual patients and their families. Although the exact mechanisms are not understood, there is emerging evidence that blood-brain-barrier disruption and neuroinflammation may play a role in developing postoperative delirium. Tranexamic acid, frequently used in cardiac surgery for its transfusion-sparing effect, has recently been shown to ameliorate neuroinflammation and stabilise the blood-brain barrier. This study investigates if there is a dose-dependent effect of tranexamic acid on developing postoperative delirium after cardiac surgery on cardiopulmonary bypass. METHODS: 5525 patients were included in this retrospective, observational database study. Patients were divided into three groups, depending on the dose of tranexamic acid they had received before heparinisation (Group A (n = 1780) up to 22 mg/kg, Group B (n = 2130) 22.01 - 27 mg/kg, and Group C (n = 1615) 27.01 mg/kg or more). All three doses are clinically relevant and seen regularly. The presence of postoperative delirium was defined by at least one "CAM-ICU positive" entry in the patient's medical record. RESULTS: There was no statistically significant difference between the three groups in the incidence of postoperative delirium. The percentage of CAM-ICU-positive patients in each group was in keeping with the overall cohort (Overall = 18%, Group A = 18%, Group B = 17%, Group C = 20%, p = 0.25). CONCLUSION: The results do not support the theory that tranexamic acid given in the higher clinically acceptable dose range decreases the incidence of postoperative delirium after cardiac surgery.
Gavin-Veyna J, Troester CT, Homann R
… +3 more, Varela S, Lickert A, Sanderson SC
J Extra Corpor Technol
· 2025 Dec · PMID 41405032
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BACKGROUND: During cardiopulmonary bypass (CPB), anticoagulation of the blood is the paramount responsibility of a perfusionist. The perfusionist should ensure the termination of cardiotomy suction at the onset of protam...BACKGROUND: During cardiopulmonary bypass (CPB), anticoagulation of the blood is the paramount responsibility of a perfusionist. The perfusionist should ensure the termination of cardiotomy suction at the onset of protamine sulfate (protamine) administration to prevent compromising the integrity of the extracorporeal circuit (AmSect. Standards and Guidelines for Perfusion Practice. 2023. https://www.amsect.org/Policy-Practice/AmSECTs-Standards-and-Guidelines). Although coagulopathy causes the largest mortality risk in adult CPB cases, standardization is not seen universally, and practice often varies between institutions (Stammers et al. Perfusion. 2001;16(3):189-198. https://doi.org/10.1177/026765910101600304; Jansa et al. Ann Thorac Surg. 2022;113(2):506-510. https://doi.org/10.1016/j.athoracsur.2021.04.059). METHODS: Activated clotting times (ACTs) were measured in five swine subjects that were heparinized and placed on CPB for a total of approximately 6 h each. Samples of blood were drawn from the CPB circuit; ACTs were measured before the administration of protamine, after a protamine test dose (PTD), and after 1/3 of the full protamine dose had been introduced to each sample. Protamine dosing was determined by a 1:100 ratio of protamine to heparin. RESULTS: 60 blood samples were included in the final analysis. The mean ACT after the PTD was 290.4 s (seconds), and 147.5 s after 1/3 of the full protamine dose. ACTs after the PTD decreased significantly by an average of 38.2% (p < 0.0001), and by 50.8% (p < 0.0001) after 1/3 of the full protamine dose was given. CONCLUSION: This investigation demonstrated an analysis of heparin reversal via protamine administration. The findings revealed that in the majority of samples, the PTD was sufficient to decrease the ACT below 480 s, the determined benchmark upon which CPB can be safely conducted. After 1/3 of the full protamine dose was given, nearly every sample's ACT reached a value considered unsafe for bypass. The interpretation of the data suggests that there are significant grounds for advocating for a more disciplined approach to cardiotomy suction termination to preserve the integrity of the CPB circuit and to safely conduct CPB.
J Extra Corpor Technol
· 2025 Sep · PMID 40953249
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The demand for allied healthcare professionals has surged, raising concerns about the rising costs of education. Tuition for post-baccalaureate and master's programs in perfusion technology ranges from $18,000 to $106,50...The demand for allied healthcare professionals has surged, raising concerns about the rising costs of education. Tuition for post-baccalaureate and master's programs in perfusion technology ranges from $18,000 to $106,500 annually, often surpassing $100,000 in total expenses. This financial burden presents significant challenges for prospective students, restricting their entry into the field. High costs could lead to a reduction in the number of qualified perfusionists, negatively impacting patient care. To address these challenges, partnerships between academic institutions and healthcare organizations could facilitate the development of scholarships or sponsored work studies. Additionally, policymakers should advocate for increased funding and other initiatives to help alleviate the financial strain allied health professionals face. Creating innovative solutions to these financial challenges may lead to a more diverse group of professionals in the field, enriching perspectives and approaches to patient care. Investing in accessible education will strengthen the healthcare system, benefiting providers and patients.
J Extra Corpor Technol
· 2025 Sep · PMID 40953248
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Published literature about patients with polycythemia vera (PV) undergoing cardiac surgery while utilizing cardiopulmonary bypass (CPB) is scarce, even more so when coupled with an additional rare bleeding disorder. Thes...Published literature about patients with polycythemia vera (PV) undergoing cardiac surgery while utilizing cardiopulmonary bypass (CPB) is scarce, even more so when coupled with an additional rare bleeding disorder. These patients require a multidisciplinary approach to achieve optimal clinical management. Several cases have been reported of oxygenator failure or thrombosis within the extracorporeal circuit. We present a successful CPB run on a patient with coexisting PV and Factor X deficiency undergoing coronary artery bypass grafting.
J Extra Corpor Technol
· 2025 Sep · PMID 40953247
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A 71-year-old male with a history of chronic thromboembolic pulmonary hypertension scheduled for an elective pulmonary thrombectomy was removed from the surgical list in 2019 for unknown reasons. Four years later, a diff...A 71-year-old male with a history of chronic thromboembolic pulmonary hypertension scheduled for an elective pulmonary thrombectomy was removed from the surgical list in 2019 for unknown reasons. Four years later, a different surgeon elected to perform the surgery with cardiopulmonary bypass support. Following surgery, the patient was placed on extracorporeal membrane oxygenation and ultimately died. This case report highlights the surgical and perfusion techniques, as well as the rare events that occurred during his care.
Danzer E, Flohr SJ, Hedrick HL
… +3 more, Bird GL, Chen JM, Rintoul NE
J Extra Corpor Technol
· 2025 Sep · PMID 40953246
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Repeat extracorporeal membrane oxygenation (ECMO) is rare in children with congenital diaphragmatic hernia (CDH). Improving our understanding of the potential survival benefits, complications, and surgical challenges ass...Repeat extracorporeal membrane oxygenation (ECMO) is rare in children with congenital diaphragmatic hernia (CDH). Improving our understanding of the potential survival benefits, complications, and surgical challenges associated with this procedure is essential for enhancing decision-making regarding multicourse ECMO in CDH. We report the case of a now 3-year-old girl who required cannulation through median sternotomy 5 months after her initial neonatal ECMO treatment via cervical venoarterial cannulation. This second run of ECMO was performed due to an acute exacerbation of pulmonary hypertension caused by urosepsis. This case illustrates that repeat ECMO should be considered for selected CDH patients when a reversible cause for clinical deterioration is identified. We also emphasize the importance of interdisciplinary decision-making, considering alternative cannulation methods, and providing appropriate family counseling. It is crucial to balance the potential survival benefits of repeat ECMO against the increased risks of morbidity.
J Extra Corpor Technol
· 2025 Sep · PMID 40953245
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This article describes two novel strategies to convert a veno-arterial extracorporeal membrane oxygenator (V-A ECMO) supported pediatric patient circuit to a cardiopulmonary bypass (CPB) circuit. Modification of the exis...This article describes two novel strategies to convert a veno-arterial extracorporeal membrane oxygenator (V-A ECMO) supported pediatric patient circuit to a cardiopulmonary bypass (CPB) circuit. Modification of the existing ECMO circuit incorporated a venous reservoir, cardioplegia circuit, ultrafiltration circuit, and cardiotomy suckers, allowing all aspects of cardiac surgery to be performed. This approach eliminated the need for conversion to an additional CPB circuit, thereby reducing surface area exposure and blood product requirement. We found that these patients had no major post-operative coagulopathies or observable neurological dysfunction.
J Extra Corpor Technol
· 2025 Sep · PMID 40953244
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The development of multi-organ failure resulting from cardiopulmonary bypass (CPB) is acknowledged as a significant contributor to increased morbidity and mortality rates during the postoperative period. This report disc...The development of multi-organ failure resulting from cardiopulmonary bypass (CPB) is acknowledged as a significant contributor to increased morbidity and mortality rates during the postoperative period. This report discusses a patient who presents with multiple comorbidities, including renal failure, reduced ejection fraction, and a history of hypertension, and is being considered for coronary artery bypass grafting (CABG) along with aortic valve replacement surgery. The administration of CPB was customized to address the unique comorbid conditions of the patient, highlighting the critical objective of maintaining an oxygen delivery index (DOi) exceeding 280 mL/min/m, while also integrating pulsatile flow methodologies. The management of CPB, as previously discussed, resulted in a notable enhancement of kidney function, accompanied by a reduction in the patient's lactate levels post-surgery.
Takeichi T, Morimoto Y, Yamada A
… +7 more, Tanaka T, Fujiwara K, Sato M, Toma R, Mitsui K, Sugita T, Gan K
J Extra Corpor Technol
· 2025 Sep · PMID 40953243
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The surgical management of preoperative malperfusion poses considerable challenges, particularly in cases of acute type A aortic dissection (TAAD). Herein, we describe the case of a 78-year-old female patient presenting...The surgical management of preoperative malperfusion poses considerable challenges, particularly in cases of acute type A aortic dissection (TAAD). Herein, we describe the case of a 78-year-old female patient presenting with TAAD complicated by malperfusion of the left lower extremity and an entry tear localized to the ascending aorta. During the initiation of cardiopulmonary bypass (CPB), a pronounced bilateral discrepancy in radial mean arterial blood pressure (mABP) was identified, alongside a significant reduction in cerebral tissue oxygenation index (TOI) and the oxyhemoglobin change rate (ΔHbO). To mitigate the malperfusion, pulsatile flow (PF) was utilized during CPB. This report elucidates the meticulous application of PF during CPB in the management of this complex malperfusion scenario, culminating in a favorable postoperative outcome.
J Extra Corpor Technol
· 2025 Sep · PMID 40953242
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BACKGROUND: The use of VA extracorporeal membrane oxygenation (ECMO) for cardiac recovery is widely adopted, with extensive publications on assessing readiness to wean from VA ECMO. Techniques to reduce ECMO support vary...BACKGROUND: The use of VA extracorporeal membrane oxygenation (ECMO) for cardiac recovery is widely adopted, with extensive publications on assessing readiness to wean from VA ECMO. Techniques to reduce ECMO support vary, including reducing flows to a low continuous cardiac index, adding bridges, temporary flow cessation, or decreasing ECMO RPMs. METHOD: We propose an alternative method involving repeated cycles of 3-4 min of ECMO flow cessation ("clamp") followed by a 30-second return ("flash") of flow. This method requires additional anticoagulation to achieve an elevated ACT, targeting 220 s for adults and 210 s for pediatrics with heparin drip and bolus, or 240 s for adults and 225 s for pediatrics with bivalirudin drip and heparin bolus. During the clamp period, flow is stopped in adult ECMO circuits with a single venous line clamp, while in pediatric circuits, flow continues via the manifold shunt but is stopped in the arterial and venous lines with a single venous line clamp. Flashing the circuit resumes patient flow for 30 s to circulate stagnant blood. RESULTS: This method significantly reduces support during the trial, which lasts one hour for adults and up to two hours for pediatric patients. The heart is unsupported 85-90% of the time, with an 85% decrease in cardiac support compared to low-flow trials. CONCLUSION: Since 2011, our center has used this technique without thrombotic complications when the protocol is followed. Most patients removed from ECMO did not require reinstitution, with rare cases needing VV support or VA support due to sepsis onset.
J Extra Corpor Technol
· 2025 Sep · PMID 40953241
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Precise temperature management during cardiopulmonary bypass (CPB) is crucial for optimizing patient outcomes, and influencing metabolic rate, organ protection, and neurological integrity. Traditionally, temperature cont...Precise temperature management during cardiopulmonary bypass (CPB) is crucial for optimizing patient outcomes, and influencing metabolic rate, organ protection, and neurological integrity. Traditionally, temperature control during CPB has relied on manual adjustments by perfusionists, a practice fraught with potential for human error and variability in outcomes. Such variability can lead to severe complications, including cerebral hyperthermia and inflammatory responses, which significantly impact patient recovery and morbidity. This paper introduces a novel, fully automated temperature management system, which integrates with existing heater-cooler units (HCUs) and advanced perfusion systems to enhance precision and reliability. By utilizing real-time physiological monitoring and intelligent automation, the system dynamically adjusts temperature phases based on continuous patient feedback. Preliminary simulation data are presented to validate the system's feasibility and responsiveness. Ethical considerations regarding automated decision-making in surgery are also briefly discussed.