Hypothermic cardiac arrest can result in a good outcome when patients are rewarmed using extracorporeal life support (ECLS), but patient selection for this treatment is challenging. The HELP score (Hemoglobin, Exposure,...Hypothermic cardiac arrest can result in a good outcome when patients are rewarmed using extracorporeal life support (ECLS), but patient selection for this treatment is challenging. The HELP score (Hemoglobin, Exposure, Lactate, Potassium) is a novel prognostic tool for estimating the survival chances of patients with non-asphyxial hypothermic cardiac arrest rewarmed with ECLS. In this retrospective multicenter study, we performed external validation of the HELP score and evaluated its clinical utility. We calculated predicted survival based on the original HELP equation and assessed overall performance, discrimination, calibration, and decision curve analysis. The study population included 106 patients from eight countries. The survival rate to hospital discharge was 65% (69/106); a favorable neurological outcome was found in 88% of survivors. The HELP score showed excellent discrimination (area under the receiver operating characteristic curve 0.80) and good overall performance (Brier 0.17). Calibration analysis showed a mild underestimation of survival (slope 0.92; intercept 0.64). Decision curve analysis showed a positive net benefit compared with a "treat all" strategy across a wide range of thresholds. The HELP score revealed excellent discrimination, good overall performance, and clinically meaningful positive net benefit in the external validation cohort. This model can be a useful aid in decisions on ECLS application in adult patients with non-asphyxia-related hypothermic cardiac arrest, but it should not replace a team-based, multidisciplinary approach.
Congenital lung malformations (CLMs) are rare developmental anomalies that can cause severe respiratory failure in early infancy, occasionally necessitating extracorporeal membrane oxygenation (ECMO). This study aimed to...Congenital lung malformations (CLMs) are rare developmental anomalies that can cause severe respiratory failure in early infancy, occasionally necessitating extracorporeal membrane oxygenation (ECMO). This study aimed to determine the incidence of ECMO use and identify predictors of survival among infants with isolated CLMs who required ECMO support. We conducted a retrospective cohort study using the Extracorporeal Life Support Organization (ELSO) registry from 2000 to 2024. The primary outcome was survival to hospital discharge. Bivariate and multivariable logistic regression analyses were performed. Among 451 infants, overall survival was 47%. The majority were neonates (< 28 days, 88%). Survival varied by CLM subtype: congenital pulmonary airway malformation (CPAM, 67%), followed by congenital lobar emphysema (CLE, 50%) and other CLMs (42%) (p < 0.001). Higher weight at ECMO initiation was associated with survival (odds ratio [OR]: 1.39, 95% CI: 1.10-1.78), and so was use of postnatal corticosteroids (OR: 1.99, 95% confidence interval [CI]: 1.15-3.49). Extracorporeal cardiopulmonary resuscitation (ECPR), hemorrhagic complications, and neurologic complications were independently associated with higher mortality. Survival among infants with CLMs requiring ECMO varies by diagnosis subtype, weight, and clinical complications. These findings offer important insights into risk stratification and may inform clinical decision-making.
Identifying suitable candidates for extracorporeal membrane oxygenation (ECMO) is still challenging. Our aim is to leverage machine learning (ML) to predict survival and identify critical variables influencing outcomes i...Identifying suitable candidates for extracorporeal membrane oxygenation (ECMO) is still challenging. Our aim is to leverage machine learning (ML) to predict survival and identify critical variables influencing outcomes in pediatric patients requiring venovenous ECMO (VV-ECMO). This retrospective study used the Extracorporeal Life Support Organization (ELSO) registry to develop conventional ML algorithms and a transfer learning approach pretrained on the Multiparameter Intelligent Monitoring in Intensive Care IV (MIMIC-IV) database. The study included 4,169 pediatric patients (aged < 19 years). Model performance was assessed through internal and external validation using independent 2024 data for external testing. Overall survival to discharge was 73.2%. The transfer learning model achieved the highest predictive performance on external validation (accuracy: 0.73). It demonstrated robust results for survivors (recall: 0.92, F1-score: 0.83), although mortality prediction was significantly lower (F1-score: 0.29) due to outcome imbalance. Respiratory rate, SaO2, SpO2, and patient height were the most influential predictors across models. Transfer learning demonstrates strong predictive capacity for survival in pediatric VV-ECMO. Although significant outcome imbalance currently hinders mortality prediction, this methodology identifies key clinical variables. Future research should focus on ML techniques resilient to imbalanced outcomes to develop reliable clinical decision-support tools.
Little is known about the outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiopulmonary arrest occurring after major cardiac surgery. This study aimed to evaluate our institutional experience with E...Little is known about the outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) for cardiopulmonary arrest occurring after major cardiac surgery. This study aimed to evaluate our institutional experience with ECPR in this setting. We retrospectively reviewed all adult patients who underwent extracorporeal membrane oxygenation (ECMO) for cardiopulmonary arrest within 30 days after major cardiac surgery outside the operating room between 2015 and 2023. Baseline characteristics, operative details, and clinical outcomes were analyzed. A total of 21 patients who underwent ECPR were identified. Index operations included valve surgery (n = 5), coronary artery bypass grafting (CABG) (n = 10), and others. The location of arrest was the intensive care unit (ICU) in 8 patients (38.1%) and the step-down unit in 13 patients (61.9%). Nine patients (42.9%) underwent central cannulation with an open chest, and 12 (57.1%) underwent femoral cannulation with chest compressions. Twelve patients (57.4%) were successfully decannulated, whereas nine (42.6%) died while on ECMO. In-hospital mortality was 47.6% (n = 10) and similar between central and femoral cannulation (44.4 vs. 50.0%; p = NS). Of the 11 in-hospital survivors, 7 (33.3%) were neurologically intact at discharge. Kaplan-Meier analysis showed a 1 year survival rate of 41.2%.
Emerging evidence links veno-venous extracorporeal membrane oxygenation (VV-ECMO) to right ventricular (RV) dysfunction, but the relative contribution of ECMO versus underlying disease progression remains unclear. We con...Emerging evidence links veno-venous extracorporeal membrane oxygenation (VV-ECMO) to right ventricular (RV) dysfunction, but the relative contribution of ECMO versus underlying disease progression remains unclear. We conducted a multicenter, retrospective, propensity-matched study including 408 intubated acute respiratory distress syndrome (ARDS) patients who were admitted between January 2020 and October 2024 in a quaternary referral hospital network within the United States and underwent at least two transthoracic echocardiograms (TTEs) after intubation. Using 1:2 propensity score matching, we adjusted for baseline comorbidities, baseline hemoglobin, lactate, and worst PaO2/FiO2 ratio (P/F). Longitudinal echocardiographic changes were analyzed with a cumulative link mixed model (CLMM), evaluating RV size and function as ordinal outcomes. Within 408 patients (112 received ECMO support), propensity matching identified 55 ECMO and 110 non-ECMO patients with balanced baseline characteristics. Among 469 serial echocardiograms, RV size and function worsened more frequently in ECMO patients. In longitudinal modeling, ECMO use alone was not associated with RV dilation (p = 0.23) or dysfunction (p = 0.43). However, longer ECMO duration was associated with RV dilation (OR: 1.04 per day, p = 0.004) and dysfunction (odds ratio [OR]: 1.04 per day, p < 0.001). Higher ECMO circuit flow had a trend toward progressive RV dilation and dysfunction but did not reach statistical significance. These findings highlight the need for vigilant RV monitoring during ECMO support.
We describe a case of a newborn with biventricular failure who successfully underwent conversion to stage I single ventricle physiology with an atrial septectomy and aortopulmonary shunt placement for single ventricular...We describe a case of a newborn with biventricular failure who successfully underwent conversion to stage I single ventricle physiology with an atrial septectomy and aortopulmonary shunt placement for single ventricular assist device (SVAD) support as an alternative to neonatal biventricular assist device (BiVAD) support. She was transitioned from a paracorporeal continuous device to a paracorporeal pulsatile device, which required interval pump-upsizing and shunt angioplasty. She was well supported for more than 15 months before receiving an orthotopic heart transplant (OHT). In selected circumstances in neonatal and infant biventricular failure, single ventricle conversion and SVAD placement may be considered as an alternative to BiVAD placement, with the potential to mitigate hematologic adverse events and mortality risk and improve rehabilitation before OHT.
Thrombotic thrombocytopenic purpura (TTP) is a rare hematologic emergency that can rapidly progress to multiorgan failure and death if untreated. The role of extracorporeal membrane oxygenation (ECMO) in this setting is...Thrombotic thrombocytopenic purpura (TTP) is a rare hematologic emergency that can rapidly progress to multiorgan failure and death if untreated. The role of extracorporeal membrane oxygenation (ECMO) in this setting is limited, and extracorporeal cardiopulmonary resuscitation (ECPR) has not been previously described. We report a case of a pregnant woman with suspected TTP who developed refractory pulseless electrical activity cardiac arrest before initiation of plasma exchange. Extracorporeal cardiopulmonary resuscitation with venoarterial ECMO was initiated despite profound thrombocytopenia (platelets 8,000/μL) as a bridge to definitive therapy, with rapid recovery of cardiac and renal function. She achieved full neurologic recovery and was discharged home without functional deficits. This case highlights the potential role of ECPR as a life-saving bridge in selected patients with TTP despite severe thrombocytopenia.
Blood coagulation analysis is essential for evaluating bleeding and clotting risks, particularly in extracorporeal life support (ECLS) patients receiving preventative anticoagulant therapy, like heparin or bivalirudin. T...Blood coagulation analysis is essential for evaluating bleeding and clotting risks, particularly in extracorporeal life support (ECLS) patients receiving preventative anticoagulant therapy, like heparin or bivalirudin. Therapy management requires continuous monitoring; however, existing methods exhibit high variability and require relatively large blood volumes, limiting their use in neonatal and pediatric care. This study assesses the ability of integrated quasistatic acoustic tweezing thromboelastometry (i-QATT), a novel noncontact technique utilizing small blood samples (6 µl), to monitor anticoagulant therapy. Integrated quasistatic acoustic tweezing thromboelastometry analysis was conducted on platelet-poor plasma samples collected from pediatric ECLS patients treated with unfractionated heparin (UFH) or bivalirudin, while heparinase was applied to neutralize the anticoagulation effect of UFH. Integrated quasistatic acoustic tweezing thromboelastometry accurately detected UFH and bivalirudin effects and UFH reversal in commercial and patient plasma samples, where clot initiation time, clotting time, and time to firm clot formation were identified as key i-QATT parameters in anticoagulant monitoring. The technique demonstrated sensitivity to anticoagulant dosage levels, effectively distinguished between different anticoagulants, and exhibited strong correlations with gold-standard plasma coagulation tests and rotational thromboelastometry. Additionally, i-QATT showed potential in assessing dynamic changes in thrombosis during the treatment period. The findings of this study highlight i-QATT's ability to monitor anticoagulant therapy in pediatric patients.
Heart transplantation continues to be the definitive treatment for end-stage heart failure, but organ availability limits access nationwide. Donation after circulatory death (DCD) hearts have shown tremendous promise as...Heart transplantation continues to be the definitive treatment for end-stage heart failure, but organ availability limits access nationwide. Donation after circulatory death (DCD) hearts have shown tremendous promise as a viable avenue for expanding the donor pool. Still, the expanded utilization of DCD hearts has introduced new challenges that evaluating centers must work to address. Among these is the frequently variable and incomplete diagnostic information available on DCD donors before organ procurement. In this case report, we highlight the role of intraoperative surface echocardiography as a practical strategy for confirming organ suitability for transplant during DCD heart recovery with thoracoabdominal normothermic regional perfusion (TA-NRP). In specific circumstances where preoperative echocardiography is not feasible, but other diagnostic data support organ suitability for transplant, intraoperative surface echocardiography may serve as a valuable tool to increase organ utilization and improve access to life-saving transplantation.
Infective endocarditis (IE) complicated by refractory cardiopulmonary failure carries high mortality, and standardized protocols for extracorporeal membrane oxygenation (ECMO) are lacking. We report a 31 year old male wi...Infective endocarditis (IE) complicated by refractory cardiopulmonary failure carries high mortality, and standardized protocols for extracorporeal membrane oxygenation (ECMO) are lacking. We report a 31 year old male with fulminant IE, severe aortic regurgitation, acute respiratory distress syndrome (ARDS), and refractory cardiogenic shock who was initially supported with venovenous (VV) ECMO for isolated respiratory failure. Due to progressive hemodynamic deterioration, configuration was converted to veno-arterial (VA) ECMO, followed by emergency aortic valve replacement and targeted antimicrobial therapy. The patient achieved successful decannulation and discharge. To contextualize this case, we conducted a systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 21 additional cases (2000-2025), forming a 22-patient cohort. Pooled analysis demonstrated an overall in-hospital survival rate of 81.8% (18/22) with ECMO bridging. Surgical treatment significantly improved survival compared with conservative management (94.4% vs. 25%). These findings suggest that ECMO is a feasible bridge-to-surgery strategy for IE with refractory cardiopulmonary failure. However, given the significant risk of publication bias inherent to case report data, we propose a hypothesis-generating management algorithm emphasizing individualized mode selection and early surgical source control, rather than definitive clinical guidelines. Large-scale prospective studies are required for validation.
Peak oxygen uptake (pVO 2 ) is a validated prognostic marker in advanced heart failure (HF), but its value in contemporary recipients of left ventricular assist devices (LVAD) is uncertain. We assessed whether pVO 2 pred...Peak oxygen uptake (pVO 2 ) is a validated prognostic marker in advanced heart failure (HF), but its value in contemporary recipients of left ventricular assist devices (LVAD) is uncertain. We assessed whether pVO 2 predicts long-term clinical outcomes in a cohort of exclusively HeartMate 3 recipients. We retrospectively studied 250 recipients at two European centers (2015-2025) who completed cardiopulmonary exercise testing 90-400 days postimplant. The median age was 56.7 years, 29% were female, and the median pVO 2 was 13.0 (10.7-16.8) ml/kg/min. Low pVO 2 (≤12 ml/kg/min on β-blocker or ≤14 off) was observed in 52%. During a median follow-up of 770 days, low pVO 2 was associated with inferior 5-year overall survival (57% vs . 84%; hazard ratio [HR], 3.23; 95% confidence interval [CI], 1.49-7.14) and survival free from heart failure recurrence (44% vs . 78%; HR, 3.13; 95% CI, 1.69-5.88). Each 1 ml/kg/min increase in pVO 2 reduced the hazard of death or HF recurrence by 16% ( p < 0.001). Low pVO 2 was also associated with a greater hospitalization burden and more ventricular arrhythmias, but no association with hemocompatibility-related adverse events. In contemporary LVAD recipients, pVO 2 predicts mortality and clinically relevant nonmortality outcomes, supporting cardiopulmonary exercise testing for long-term risk stratification and management in stable LVAD patients.
Post-myocardial infarction ventricular septal defect is a catastrophic mechanical complication frequently associated with acute right ventricular failure and high mortality. Veno-arterial extracorporeal membrane oxygenat...Post-myocardial infarction ventricular septal defect is a catastrophic mechanical complication frequently associated with acute right ventricular failure and high mortality. Veno-arterial extracorporeal membrane oxygenation (ECMO) is commonly used for temporary circulatory support; however, persistent left-to-right shunting and severe right ventricular dysfunction may limit successful myocardial recovery. We report the use of prolonged isolated right ventricular mechanical support with the ProtekDuo cannula in a patient with inferior myocardial infarction complicated by ventricular septal defect and refractory cardiogenic shock. After unsuccessful surgical repair and inability to wean from prolonged ECMO support, the patient was transitioned to ProtekDuo-based right ventricular assist support using a centrifugal pump. This approach resulted in hemodynamic stabilization, withdrawal of veno-arterial support, and reduced vasoactive requirements. Right ventricular assist support was maintained for 51 consecutive days without device-related complications, allowing myocardial recovery and enabling subsequent percutaneous closure of the residual septal defect. Successful weaning from mechanical circulatory support was achieved after a total of 77 days. To our knowledge, this represents one of the longest reported durations of isolated right ventricular support using the ProtekDuo system. This case supports the feasibility and durability of prolonged ProtekDuo right ventricular assistance as a bridge to recovery in complex post-infarction complications.
Ventricular assist device (VAD) in adult congenital heart disease (ACHD) patients remains technically demanding because of complex anatomy, prior surgical interventions, and hemodynamics. This study aimed to describe ana...Ventricular assist device (VAD) in adult congenital heart disease (ACHD) patients remains technically demanding because of complex anatomy, prior surgical interventions, and hemodynamics. This study aimed to describe anatomical and device-related challenges during durable VAD support in ACHD patients. We retrospectively reviewed ACHD patients who underwent durable VAD implantation at a single institution between 2012 and 2023. Clinical and anatomical characteristics were analyzed. Four ACHD patients (median age, 37 years) underwent VAD implantation for end-stage heart failure. Primary disease was l- and d-transposition of the great arteries and atrioventricular septal defect. All patients had complex anatomy and extensive surgical histories. Ventricular assist device implantation required individualized surgical strategies, including device placement in the expanded thoracic space and nonstandard inflow and outflow graft configurations, and concomitant procedures. During long-term follow-up, patients experienced diverse complications such as driveline infection with gastrointestinal erosion and external outflow graft obstruction due to mediastinal compression. Two patients were successfully bridged to heart transplantation, whereas one patient died of sepsis, and one patient is alive on a device. Ventricular assist device therapy in ACHD patients is feasible but is associated with unique anatomical and device-related challenges. Careful surgical planning, individualized surgical approaches, and vigilant long-term management may help optimize VAD support in this complex population.
HeartMate 3 (HM3) left ventricular assist devices (LVADs) have improved hemocompatibility and reduced morbidity; however, late device-related complications continue to be recognized. External outflow graft obstruction at...HeartMate 3 (HM3) left ventricular assist devices (LVADs) have improved hemocompatibility and reduced morbidity; however, late device-related complications continue to be recognized. External outflow graft obstruction at the bend relief region (EOGO-BR) is an uncommon but potentially life-threatening condition, and data regarding its diagnosis and management remain limited. Three symptomatic male patients with biomaterial-related EOGO-BR following HM3 implantation were retrospectively reviewed. Clinical presentation, diagnostic imaging, surgical management, and outcomes were evaluated. All patients presented with low-flow alarms associated with heart failure symptoms, including dyspnea, fatigue, and reduced exercise tolerance. Computed tomography angiography (CTA) demonstrated external compression of the outflow graft in all cases and was the primary diagnostic modality. Surgical evacuation of accumulated biomaterial via left thoracotomy resulted in immediate restoration of LVAD flow in all patients. Two patients showed favorable postoperative recovery with sustained clinical improvement during follow-up. One patient, who presented with concomitant sepsis, died despite surgical intervention and advanced mechanical circulatory support. External outflow graft obstruction at the bend relief region represents an uncommon but serious late complication of HM3 LVAD support. Computed tomography angiography is a valuable diagnostic tool for timely identification. Surgical removal of accumulated biomaterial provides immediate hemodynamic improvement and appears to be an effective and durable treatment strategy in selected patients.
In the accompanying article in this issue, we reported the survival of a 4 month old infant with severe necrotizing pneumonia due to respiratory syncytial virus (RSV) and methicillin-resistant Staphylococcus aureus (MRSA...In the accompanying article in this issue, we reported the survival of a 4 month old infant with severe necrotizing pneumonia due to respiratory syncytial virus (RSV) and methicillin-resistant Staphylococcus aureus (MRSA), resulting in cardiogenic shock and respiratory failure, who required a total of 233 days of extracorporeal membrane oxygenator (ECMO) support. In this article, we report the function of the ECMO membrane (oxygenator). To preserve oxygenator function, nitric oxide was added to the ECMO sweep gas (sNO). Despite prolonged ECMO support, a single membrane lung functioned effectively for 5 months. Structural analysis of the polymethylpentene (PMP) oxygenator postdecannulation revealed no thrombus or fibrin deposition. This is the first known structural evaluation of a PMP oxygenator after prolonged clinical use with sNO, suggesting that sNO may prolong oxygenator longevity and maintain functional performance.
Neonatal fluid management in extracorporeal life support (ECLS) is complex, with the goal of improving outcomes while preventing complications. This study evaluates the impact of early continuous renal replacement therap...Neonatal fluid management in extracorporeal life support (ECLS) is complex, with the goal of improving outcomes while preventing complications. This study evaluates the impact of early continuous renal replacement therapy (CRRT) on volume status, outcomes, and renal recovery in neonatal ECLS. A single-center retrospective review of neonates was performed (2007-2023, n =108). Routine early CRRT began in 2011, providing a natural cohort comparison between early (≤48 hours) and delayed/no CRRT. Early (70.4%) and delayed/no (29.6%) CRRT cohorts had similar ECLS indications, birthweights, and mortality. Time from cannulation to CRRT initiation was 4 hours (early CRRT) versus 4.4 days (delayed CRRT) (p < 0.001). Early CRRT was associated with significantly reduced median peak fluid balance (30% vs. 37%, p < 0.05) and earlier negative volume status, with 80% achieving negative fluid balance by day 3, compared with 53% in the delayed group (p = 0.030). In survivors, early CRRT had significantly shorter ECLS runs (5.1 vs. 8.6 days, p < 0.001) with fewer median extrarenal ECLS complications (1.0 vs. 3.0, p = 0.001). No differences were observed in renal recovery. Though the study design prohibits definitive conclusions, early CRRT initiation in neonatal ECLS was associated with improvement in early and peak fluid balance status and reduced ECLS duration and complications without differences in long-term renal outcomes.