Extracorporeal Membrane Oxygenation Group Research Articles

Bridge-to-transplant temporary mechanical circulatory support and risk of allosensitization.

Since the 2018 change in the US adult heart allocation policy, more patients are bridged-to-transplant on temporary mechanical circulatory support (tMCS). Previous studies indicate that durable left ventricular assist devices (LVAD) may lead to allosensitization. The goal of this study was to assess whether tMCS implantation is associated with changes in sensitization. We included patients evaluated for heart transplants between 2015 and 2022 who had alloantibody measured before and after MCS implantation. Allosensitization was defined as development of new alloantibodies after tMCS implant. A total of 41 patients received tMCS before transplant. Nine (22.0%) patients developed alloantibodies following tMCS implantation: 3 (12.0%) in the intra-aortic balloon pump group (n=25), 2 (28.6%) in the microaxial percutaneous LVAD group (n=7), and 4 (44.4%) in the veno-arterial extra-corporeal membrane oxygenation group (n=9)-p=.039. Sensitized patients were younger (44.7±11.6 years vs. 54.3±12.5 years, p=.044), were more likely to be sensitized at baseline - 3 of 9 (33.3%) compared to 2 out of 32 (6.3%) (p=.028) and received more transfusions with red blood cells (6 (66.6%) vs. 8 (25%), p=.02) and platelets (6 (66.6%) vs. 5 (15.6%), p=.002). There was no significant difference in tMCS median duration of support (4 [3,15] days vs. 8.5 [5,14.5] days, p=.57). Importantly, out of the 11 patients who received a durable LVAD after tMCS, 5 (45.5%) became sensitized, compared to 4 out of 30 patients (13.3%) who only had tMCS-p=.028. Our findings suggest that patients bridged-to-transplant with tMCS, without significant blood product transfusions and a subsequent durable LVAD implant, have a low risk of allosensitization. Further studies are needed to confirm our findings and determine whether risk of sensitization varies by type of tMCS and duration of support.

Extracorporeal membrane oxygenation versus invasive ventilation in patients with COVID-19 acute respiratory distress syndrome and pneumomediastinum: A cohort trial.

Patients with severe respiratory failure due to COVID-19 who are not under mechanical ventilation may develop severe hypoxemia when complicated with spontaneous pneumomediastinum (PM). These patients may be harmed by invasive ventilation. Alternatively, veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) may be applied. We report on the efficacy of V-V ECMO and invasive ventilation as initial advanced respiratory support in patients with COVID-19 and acute respiratory failure due to spontaneous PM. This was a retrospective cohort study performed between March 2020 and January 2022. Enrolled patients had COVID-19 and acute respiratory failure due to spontaneous PM and were not invasively ventilated. Patients were treated in the intensive care unit (ICU) with invasive ventilation (invasive ventilation group) or V-V ECMO support (V-V ECMO group) as the main therapeutic option. The primary outcomes were mortality and ICU discharge at 90 days after ICU admission. Twenty-two patients were included in this study (invasive ventilation group: 13 [59%]; V-V ECMO group: 9 [41%]). The V-V ECMO strategy was significantly associated with lower mortality (hazard ratio [HR] 0.33 [95% CI 0.12-0.97], p = 0.04). Five (38%) patients in the V-V ECMO group were intubated and eight (89%) patients in the invasive ventilation group required V-V ECMO support within 30 days from ICU admission. Three (33%) patients in the V-V ECMO group were discharged from ICU within 90 days compared to one (8%) patient in the invasive ventilation group (HR 4.71 [95% CI 0.48-45.3], p = 0.18). Preliminary data suggest that V-V ECMO without invasive ventilation may improve survival in COVID-19-related acute respiratory failure due to spontaneous PM. The study's retrospective design and limited sample size underscore the necessity for additional investigation and warrant caution.

Effect of extracorporeal membrane oxygenation combined with ulinastatin

This study aims to investigate the clinical efficacy of combining extracorporeal membrane oxygenation (ECMO) with ulinastatin in the treatment of severe pneumonia (SP) with respiratory failure, using an immuno-magnetic bead-based ELISA method. A total of 40 patients with SP complicated by respiratory failure who were admitted to the respiratory department of our hospital from January 2019 to December 2022, were selected. They were divided into the control group (n = 20) and the ECMO group (n = 20). The control group received conventional therapy such as mechanical ventilation, anti-infection, anticoagulation, and maintaining acid-base balance. The ECMO group established an ECMO system and injected ulinastatin intravenously based on conventional therapy. After 7 days of treatment, arterial blood was collected for blood gas analysis and pulmonary function index. The level of inflammatory factors was determined using the immunomagnetic bead-ELISA method. Flow cytometry was used to assess T lymphocyte subsets and clinical efficacy between the two groups. The ECMO group exhibited significantly shorter length of hospital stay and mechanical ventilation duration compared to the control group. Moreover, pulmonary function indexes (FEV1, FVC, PEF) and blood gas indexes were superior in the ECMO group than those in the control group. Additionally, the ECMO group exhibited significantly reduced levels of PCT, IL6, and CRP, and elevated CD3+% and CD4+% values compared to the control group. In conclusion, the combined therapy demonstrates efficacy in the treatment of patients with SP and respiratory failure, and the immunomagnetic bead-based ELISA method enhances detection efficiency and reduces errors.

Outcome of pregnant women admitted to critical care unit with confirmed severe COVID-19: A center experience.

To explore the traits and risk factors of pregnant women admitted to intensive care units (ICUs) with COVID-19. Moreover, the study classifies outcomes based on differing levels of required respiratory support during their intensive care stay. This retrospective and descriptive study included all pregnant women with COVID-19 admitted to the adult critical care unit at a specialized tertiary hospital in Riyadh, Saudi Arabia. Between January 2020 and December 2022. A total of 38 pregnant women were identified and were eligible for our study. The mean age of the patients was 32.9 (19-45) years, and the average Acute Physiology and Chronic Health Evaluation IV (APACHI IV) score was 49.9 (21-106). Approximately 60.5% of the patients suffered from superimposed infections during their ICU stay. Approximately 81.6% patients were delivered by C-section, 33 of the newborns survived, and 5 died. The crude mortality rate among pregnant women in our cohort was 15.8%. Patients treated with high-flow nasal cannula (HFNC) were mostly discharged or delivered normally, while the mechanical ventilation (MV) and extracorporeal membrane oxygenation groups mostly underwent C-sections. Most of the surviving newborns were on HFNC and MV. Patients with multiple infections had the longest ICU stay and had the highest risk of death. The results of this study highlight the characteristics of pregnant women admitted to the ICU at a specialized tertiary healthcare center in Saudi Arabia. The APACHI IV scores accurately predicted patient's mortality, duration of MV, and length of ICU stay. In our study, we shared our experience of managing severe COVID-19 infections in pregnant patients.

In-hospital outcomes with extracorporeal membrane oxygenation alone versus combined with percutaneous left ventricular assist device

BackgroundVeno-arterial extracorporeal membrane oxygenation (ECMO) is associated with increased afterload and hindered myocardial recovery. Adding a percutaneous left ventricular assist device (pLVAD) to ECMO is one strategy to unload the left ventricle. We evaluated in-hospital outcomes in cardiogenic shock patients treated with ECMO alone versus ECMO plus pLVAD. MethodsWe conducted a retrospective study using the National Inpatient Sample database from 2011 to 2019. Logistic regression analysis was performed to adjust for covariates. Results20,171 patients were included. 16,064 (79.6 %) patients received ECMO alone and 4107 (20.4 %) patients received ECMO plus pLVAD. The ECMO plus pLVAD group had higher rates of mortality, stroke, acute kidney injury, pericardial complications, and vascular complications. After adjusting for covariates, combined therapy was associated with higher rates of mortality (OR 1.2; 95 % CI [1.1–1.3]) and stroke (OR 1.3; 95 % CI [1.2–1.5]), however lower bleeding (OR 0.7; 95 % CI [0.68–0.81]) (p < 0.001 for all). After adjusting for covariates, a subgroup analysis of 5019 patients with acute coronary syndrome cardiogenic shock (ACS-CS) demonstrated higher rates of mortality (OR 1.3; 95 % CI [1.2–1.5]) and stroke (OR 1.7; 95 % CI [1.4–2.1]; p < 0.001 for all) with combined therapy, however similar rates of bleeding compared to ECMO alone (OR 0.95; 95 % CI [0.8–1.1]; p = 0.54). ConclusionsIn the overall group, ECMO plus pLVAD was associated with increased mortality and stroke, however decreased bleeding. In a sub-group of ACS-CS, ECMO plus pLVAD was associated with increased mortality and stroke, however similar rates of bleeding compared to ECMO alone.

Veno-arterial extracorporeal membrane oxygenation reduces myocardial and mitochondrial damage in acute myocardial infarction.

Myocardial infarction (MI) is a common cardiovascular disease with a high fatality rate once accompanied by cardiogenic shock. The efficacy of extracorporeal membrane oxygenation (ECMO) in treating myocardial infarction is controversial. MI was induced by ligating the left anterior descending artery in adult male rats. Groups were defined as follows: MI group, reperfusion for 90 min after 30 min of left anterior descending artery (LAD) occlusion; MI + ECMO group, reperfusion and ECMO were performed for 90 min immediately after 30 min of LAD occlusion; prolonged MI + ECMO group, ECMO was used immediately after 30 minutes of occlusion with persistent occlusion of the LAD for an additional 30 minutes, followed by 90 minutes of reperfusion. The myocardial infarct size and mitochondrial morphology and function data were collected and compared of each group. The ECMO groups had a smaller myocardial infarct size and larger percentage ejection fraction. Compared with the prolonged MI + ECMO group, the immediate reperfusion group had a lower percentage of infarct size (63.28% versus 17.97% versus 31.22%, MI versus MI + ECMO versus prolonged MI + ECMO). Mitochondria isolated from the ischemic zone showed an intact mitochondrial structure, including fewer voids and broken crists, and preserved activity of mitochondrial complex II and complex IV in ECMO groups. ECMO support in myocardial infarction can reduce myocardial injury despite delayed coronary reperfusion.

Multicenter evaluation of left ventricular assist device implantation with or without ECMO bridge in cardiogenic shock.

The efficacy of extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) remains unclear, and recipients of the more contemporary HeartMate 3 (HM3) LVAD are not well represented in previous studies. We therefore undertook a multicenter, retrospective study of this population. INTERMACS 1 LVAD recipients from five U.S. centers were included. In-hospital and one-year outcomes were recorded. The primary outcome was the overall mortality hazard comparing ECMO versus non-ECMO patients by propensity-weighted survival analysis. Secondary outcomes included survival by LVAD type, as well as postoperative and one-year outcomes. One hundred and twenty-seven patients were included; 24 received ECMO as a bridge to LVAD. Mortality was higher in patients bridged with ECMO in the primary analysis (HR 3.22 [95%CI 1.06-9.77], p = 0.039). Right ventricular assist device was more common in the ECMO group (ECMO: 54.2% vs non-ECMO: 11.7%, p < 0.001). Ischemic stroke was higher at one year in the ECMO group (ECMO: 25.0% vs non-ECMO: 4.9%, p = 0.006). Among the study cohort, one-year mortality was lower in HM3 than in HeartMate II (HMII) or HeartWare HVAD (10.5% vs 46.9% vs 31.6%, respectively; p < 0.001) recipients. Pump thrombosis at one year was lower in HM3 than in HMII or HVAD (1.8% vs 16.1% vs 16.2%, respectively; p = 0.026) recipients. Higher mortality was observed with ECMO as a bridge to LVAD, likely due to higher acuity illness, yet acceptable one-year survival was seen compared with historical rates. The receipt of the HM3 was associated with improved survival compared with older generation devices.

Effects of Extracorporeal Membrane Oxygenation on the Coagulation System.

This study aimed to investigate the effects of long-term awake extracorporeal membrane oxygenation (ECMO) on the coagulation system in a sheep model. A total of ten healthy sheep were included in the study, with 5 sheep in each group. In the veno-arterial ECMO (V-A ECMO) group, cannulation was performed in the right carotid artery and the right external jugular vein. In the veno-venous ECMO (V-V ECMO) group, a dual-lumen catheter was utilized to insert into the right external jugular vein. After initiating ECMO, the sheep were recovered from anesthesia and remained awake for 7 days. The target activated clotting time (ACT) goal was set at 220-250 s. In both groups, the actual ACT fluctuated around 250 s with the dose of heparin gradually increasing, reaching almost 60 IU/kg/min at the end of the experiments. Moreover, the activated partial thromboplastin time (APTT) and thrombin time (TT) values were significantly higher in the V-A ECMO group compared to the V-V ECMO group, despite receiving the same doses of heparin. Although laboratory test results fluctuated within a normal and reasonable range, infarct foci in the kidneys were observed in both groups at the end of the study.

Ambulatory Extracorporeal Membrane Oxygenation Use in Patients Listed for Lung Transplant.

There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) to bridge critically ill patients to lung transplant (LTX). This study evaluates how ambulatory status on ECMO affected waitlist and post-LTX outcomes. The United Network of Organ Sharing (UNOS) database was queried for patients aged of greater than or equal to 18 years and between 2016 and 2021 to identify pre-LTX patients supported by ECMO. The patients were classified in venous-arterial (VA) ECMO and veno-venous (VV) ECMO cohorts and further classified as ambulatory (AMB) and non-AMB (nAMB). Each cohort was controlled against the non-ECMO patients. Univariate statistical tests, as well as Kaplan-Meier survival curves, were used for analysis. The 90 day waitlist survival was the highest among the non-ECMO group (96%), but both AMB VV and VA groups had superior survival compared to the nAMB group (85% vs. 75%, 78% vs. 65%, p < 0.01). After adjusting for the median lung allocation score (LAS) (88) in the VV ECMO group, the waitlist survival was superior in the AMB VV ECMO compared to those not on ECMO (86% vs. 78%, p > 0.01). The 1 year post-LTX survival between non-ECMO and AMB VV ECMO was comparable (88% vs. 88%, p = 0.66). Ambulating patients or use of physical therapy while on ECMO can help improve lung transplant outcomes.

Extracorporeal membrane oxygenation for COVID-19-associated severe acute respiratory distress syndrome in Canada: Analysis of data from the Canadian Nosocomial Infection Surveillance Program.

Extracorporeal membrane oxygenation (ECMO) for COVID-19 across Canada has not been well-described. We studied trends for patients with COVID-19-related acute respiratory distress syndrome who received ECMO. Multicentre retrospective cohort study using data from the Canadian Nosocomial Infection Surveillance Program across four different waves. Surveillance data was collected between March 2020 and June 2022. We reported data stratified by ECMO status and wave. ECMO recipients comprised 299 (6.8%) of the 4,408 critically ill patients included. ECMO recipients were younger (median age 49 versus 62 years, p < 0.001), less likely to be vaccinated against COVID-19 (Wave 4 data: 5.3% versus 19%; p = 0.002), and had fewer comorbidities compared to patients who did not receive ECMO. Thirty-day all-cause mortality was similar between the ECMO and non-ECMO groups (23% versus 26%; p = 0.25). Among ECMO recipients, mortality tended to decrease across Waves 1 to 4: 48%, 31%, 18%, and 16%, respectively (p = 0.04 for trend). However, this was no longer statistically significant when removing the high mortality during Wave 1 (p = 0.15). Our findings suggest that critically ill patients in Canadian hospitals who received ECMO had different characteristics from those who did not receive ECMO. We also observed a trend of decreased mortality over the waves for the ECMO group. Possible explanatory factors may include potential delay in ECMO initiation during Wave 1, evolution of the virus, better understanding of COVID-19 disease and ECMO use, and new medical treatments and vaccines available in later waves. These findings may provide insight for future potential pandemics.

Pulmonary Artery Measurements as Postnatal Prognostic Tool in Right Congenital Diaphragmatic Hernia

BackgroundRight-sided congenital diaphragmatic hernia (RCDH) is a rare and often fatal congenital anomaly, primarily attributed to lung hypoplasia, which is associated with small branch pulmonary artery (PA). This study investigated whether postnatal PA measurements obtained through echocardiography are associated with mortality or the extracorporeal membrane oxygenation (ECMO) requirement in neonates with RCDH. MethodsA retrospective study was conducted on neonates with RCDH born between 2008 and 2022. Echocardiography was performed on the day of birth. The diameter of the main PA (MPA) was measured at the maximal dimension, and the diameters of the left PA (LPA) and right PA (RPA) were measured at the bifurcation. The primary outcome was mortality or ECMO requirement. Parameters, including the LPA:MPA ratio, RPA:MPA ratio, Nakata index, McGoon ratio, and ejection fraction (EF), were analyzed and compared with the observed-to-expected lung-to-head ratio (o/e LHR), initial blood gas, and defect size as predictive values. ResultsAmong 39 neonates with RCDH, 25 (64.1 %) survived without ECMO. The non-survivor or ECMO group exhibited lower o/e LHR, reduced EF, smaller LPA and RPA diameters, and larger MPA diameter than survivors. Lower LPA:MPA ratio, Nakata index, McGoon ratio, and higher initial PaCO2 were associated with adverse outcomes. Notably, the LPA:MPA ratio showed the highest predictive capability (area under the curve, 0.983; p < 0.001). ConclusionThe LPA:MPA ratio is a promising postnatal predictor of mortality or ECMO requirement in neonates with RCDH. Additionally, Nakata index, McGoon ratio, and initial PaCO2 are significantly correlated with outcomes. Level of evidenceThis is a level III. Type of StudyPrognostic study.

Cefepime pharmacokinetics in adult extracorporeal membrane oxygenation patients

BackgroundThe impact of extracorporeal membrane oxygenation (ECMO) on the pharmacokinetics/dynamics (PK/PD) of beta-lactam antibiotics have not been well studied in general, but cefepime specifically has the least amount of data. We aimed to investigate whether ECMO alters the PK of cefepime in adult intensive care unit (ICU) patients. MethodsThis single-center, retrospective case-control study evaluated cefepime therapeutic drug monitoring (TDM) results from ECMO patients that were matched 1:1 with TDM results in non-ECMO patients for drug regimen and renal function. The primary outcome was the difference in PK/PD of cefepime in ECMO compared with non-ECMO ICU patients. Secondary outcomes included hospital length of stay, treatment failure, superinfection, bacterial resistance, and survival to discharge. ResultsEighty-two patients were included with 44 matched cefepime concentrations in each group. ECMO patients had higher free maximum concentrations (fCmax) (p = 0.003), lower free minimum concentration (fCmin)/1x minimum inhibitory concentration (MIC) ratios (p = 0.040), and lower attainment of free Cmin/4x MIC (p = 0.010). There were no differences between the groups for free Cmin, time above 1xMIC or 4x MIC, and pharmacokinetic parameters (ke, half-life, and Vd). Of those who survived to discharge, hospital length of stay was longer in the ECMO group (p < 0.001). Patients on ECMO were more likely to experience treatment failure (p = 0.036). The incidence of bacterial resistance, superinfection, or survival were similar among the groups. ConclusionThese data suggest that more aggressive empiric dosing may be warranted in patients on ECMO. Therapeutic drug monitoring and future prospective studies would provide more evidence to guide decision making regarding dose adjustments.

Trends in mechanical circulatory support use and outcomes of patients with cardiogenic shock in Japan, 2010-2020: a nationwide inpatient database study

Abstract Background/Introduction Little is known about the impact of the downgrade of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella in Japan, where IABPs have been enthusiastically used. Purpose This study aimed to describe the annual trends in the mechanical circulatory support (MCS) use and outcomes in patients with cardiogenic shock (CS) requiring MCS. Methods This was a retrospective cohort study using the Japanese Diagnosis Procedure Combination database, which contained administrative claims data and discharge abstracts from more than 1,500 acute care hospitals and covered approximately 90% of all tertiary emergency hospitals in Japan. Using the data from July 2010 to March 2021, we identified inpatients with CS requiring MCS. The primary outcome was in-hospital mortality. The secondary outcomes were the length of MCS, length of hospital stay, total hospitalization cost, major bleeding, ischemic stroke, continuous renal replacement therapy, and total blood transfusion volume during the hospitalization. The patients were stratified into three groups: (i) IABP alone, (ii) Impella alone, and (iii) extracorporeal membrane oxygenation (ECMO) regardless of IABP or Impella use. The patient characteristics and outcomes were reported by the fiscal year. Results Of the 160,559 eligible patients, 117,599 (73.2%) were identified as the IABP alone group, 1,465 (0.9%) as the Impella alone group, and the remaining 41,495 (25.8%) as the ECMO group. Of the overall 1,107 hospitals, IABP alone was used in 1,096 (99.0%), Impella alone in 120 (10.8%), and ECMO in 831 (75.1%). In-hospital mortality was 17.4%, 38.0%, and 68.3% in the IABP alone, Impella alone, and ECMO groups, respectively. The length of hospital stay was 32.6, 36.6, and 29.4 days and the total hospitalization cost was 4,522, 9,098, and 5,840 thousand yen in the IABP alone, Impella alone, and ECMO groups, respectively. All of major bleeding, ischemic stroke, and continuous renal replacement therapy were most prevalent in the Impella alone group and least prevalent in the IABP alone group. The prevalence of an IABP alone significantly decreased from 80.5% in 2010 to 65.3% in 2020 (P for trend &amp;lt;0.001). In contrast, the prevalence of an Impella alone significantly increased from 0.0% in 2010 to 5.0% in 2020, and the prevalence of ECMO significantly increased from 19.5% in 2010 to 29.6% in 2020. In-hospital mortality significantly increased from 29.3% in 2010 to 32.6% in 2020 in the overall patients with CS requiring MCS, but significantly decreased in those requiring ECMO from 73.7% in 2010 to 64.1% in 2020 (P for trend &amp;lt;0.001 for both). Conclusions There were significant annual changes in the patterns of MCS use and clinical outcomes in patients with CS requiring MCS.

Abstract 395: Outcomes Of Mechanical Circulatory Support for Cardiogenic Shock in the United States: An Analysis of the 2017-2020 National Inpatient Sample Database

Introduction: Mechanical circulatory support devices, such as Extracorporeal membrane oxygenation(ECMO), Impella, and intra-aortic balloon pump(IABP), play a crucial role in managing patients with cardiogenic shock(CS). This study aimed to compare the outcomes and patient characteristics of different mechanical circulatory support modalities. Methods: We utilized the National Inpatient Sample Database(NIS) data from 2017 to 2020 to identify patients with the diagnosis of CS who received mechanical circulatory support. The study population was categorized into six groups: ECMO, Impella, IABP, ECMO + Impella, and ECMO + IABP. The groups were compared based on patient characteristics, length of stay(LOS), complications, need for a heart transplant, mortality, and total charges. Results: A total of 715,470 patients were identified with CS, 17%(122,100) received mechanical circulatory support, 5,675 had ECMO therapy, 33,360 Impella, 79,540 IABP, 1,890 cases ECMO+Impella, and 1,635 cases ECMO+IABP. Age significantly differed, with ECMO patients being the youngest 54[36-65] years. There were higher proportions of females in the ECMO-only(37.4%) and males in the ECMO+Impella(76.7%). LOS was prolonged in the ECMO group(14 [5-28] days) compared to other groups(p&lt;0.001). Mortality rates were higher in the ECMO group(47.1%), followed by ECMO+Impella(45.8%) and ECMO+IABP (40.1%) (p&lt;0.001). Higher rates of stroke, disseminated intravascular coagulation, and continuous renal replacement therapy requirements were observed in the ECMO group. Bleeding requiring transfusion was more frequent with ECMO+IABP, and limb ischemia was more common in the ECMO+Impella group (p&lt; 0.001). Heart transplant rates were highest after ECMO+IABP therapy. Over the years, ECMO utilization increased, while Impella and IABP utilization remained stable. Notably, the ECMO+IABP had the highest total charges among all the therapy modalities evaluated (p &lt; 0.001). Conclusions: The rising utilization of ECMO and ECMO-IABP therapies indicates a changing treatment landscape. However, these approaches exhibit lower survival rates, potentially due to the severity of CS, heightened complications, and increased costs compared to standalone IABP or Impella therapies.

Abstract 13333: Review of Simultaneous Kidney and Heart Transplant After 2018: UNOS Data

Introduction: In October 2018, the Organ Procurement and Transplant Network (OPTN) adopted a 6-tier system for organ allocation where priority was given to critically ill patients, especially those on Extra Corporeal Membrane Oxygenation (ECMO) support. The guideline lacks information about multiorgan transplant due to weak evidence on Simultaneous Kidney and Heart transplant (SKHT) data. Hence with this study, we aim to review outcomes of patients on ECMO at the time of SKHT. Method: This was a retrospective study of adult SKHT recipients between 2018-2022 from the OPTN database. The study excluded individuals who underwent simultaneous multiple organ transplants, isolated heart transplants, as well as those with incomplete outcome information. The cohort was stratified by ECMO need at the time of transplant. Univariate cox regression analysis was performed for predictors of worse outcomes. Patient survival was compared using Kaplan Meier (KM) curve and log rank test. Results: A total of 1383 patients were included in this study, of which 72 (5.2%) were on ECMO bridge. On review of baseline characteristics, patients on ECMO had mean wait time of 65 (± 190) days with higher mortality rate post-transplant and a lower mean survival time as compared to the non-ECMO counterparts (398 (± 404) vs 545 (± 462) days, p= 0.008). On analysis of KM curve, SKHT recipients on ECMO bridge had higher mortality within the first 10 months of transplant and plateaued after that. The only predictors associated with worst outcomes among ECMO recipients were dialysis requirement and development of stroke post-transplant. On the contrary, Left Ventricular assisted device (LVAD) use prior to transplant was associated with 70% reduction in mortality in non-ECMO group (HR: 0.30 (95% CI: 0.11 - 0.83, p=0.02)) in this cohort. Conclusion: Following the change in guidelines, around 5.2% of the total SKHT recipients were on the ECMO bridge. Dialysis requirement and development of stroke post-transplant was independently associated with higher mortality compared to non ECMO group. On the contrary, patients on LVAD support at the time of transplant have had better outcomes.Figure 1:

Abstract 12573: Differences in Blood Product Consumption Between Ventricular Assist Device and Extracorporeal Membrane Oxygenation During Postoperative Period

Introduction: Mechanical circulatory supports such as veno-arterial extracorporeal membrane oxygenation (ECMO) and left ventricular assist device (LVAD) are used in advanced heart failure patients. Due to their thrombogenic surfaces, these devices can lead to disseminated thrombosis. The need for anticoagulation also predisposes to hemorrhage, in addition to hemolysis from shear stress. As a result, transfusion of blood components is usually warranted following implantation. Hypothesis: To evaluate the differences in the need for transfusion of blood products between these devices during immediate postoperative period up to day 3. Methods: Fifty-four patients with advanced heart failure patients admitted at our facility between January 2016-2019 were included. All patients were anticoagulated with continuous heparin infusion. We analyzed the need for packed red blood cells (pRBC), fresh frozen plasma (FFP), and platelet transfusion. Lactate dehydrogenase (LDH), CBC, aPTT, and PT were also measured. The study was approved by Institutional Review Board (#L19-093). Results: A total of 54 patients (25 patients received ECMO and 29 patients received LVAD) were included. The median age was 56 years [47-62]. Thirty-eight patients (70.4%) were male. The means daily substitution of pRBC were significantly lower in the LVAD group on day 2 (0.35 vs 2.64 units/day, p=0.002) and day 3 (0.58 vs 1.64 units/day, p=0.028). The means daily substitution of platelets were comparable between the ECMO and LVAD groups. A trend toward the lower mean daily substitution of FFP in the LVAD group on day 2 (0 vs 0.44 units/day, p=0.069) was seen. There was a significantly lower serum LDH in the LVAD group on day 3 (391 ± 345 vs 599 ± 268, p=0.003). Conclusions: Data from this retrospective study showed that, compared to ECMO, LVAD was associated with lower rates of hemolysis and pRBC transfusion.

Autopsy Histopathologic Lung Findings in Patients Treated With Extracorporeal Membrane Oxygenation

Context.— Extracorporeal membrane oxygenation (ECMO) is increasingly used in the treatment of respiratory and cardiac failure, but data describing lung histopathology in ECMO recipients are limited. Objective.— To examine pulmonary histopathologic findings in patients who underwent venovenous (VV) ECMO for pulmonary reasons, or venoarterial (VA) ECMO for cardiac indications shortly before death, and to determine if the pulmonary changes provided insights into therapy that may prevent complications and improve outcome. Design.— We conducted a retrospective study of lung autopsies, from VV and VA ECMO recipients and patients with acute respiratory distress syndrome (ARDS) and non-ECMO treatment, between 2008 and 2020 in Silesia Center for Heart Diseases in Zabrze, Poland. Results.— Among 83 ECMO patients (42–64 years; male, 57 [68.7%]), the most common histopathologic findings were bronchopneumonia (44 [53.0%]), interstitial edema (40 [48.2%]), diffuse alveolar damage (DAD; 32 [38.6%]), hemorrhagic infarct (28 [33.7%]), and pulmonary hemorrhage (25 [30.1%]). DAD was associated with longer ECMO treatment and longer hospital stay. The use of VV ECMO was a predictor of DAD in patients with ARDS and undergoing ECMO, but it also occurred in 21 of 65 patients (32.3%) in the VA ECMO group, even though VA ECMO was used for heart failure. Conclusions.— Although DAD was significantly more common in lung autopsies of VV ECMO patients, one-third of VA ECMO patients had histopathologic changes characteristic of ARDS. The presence of DAD in lung autopsies of patients treated with VA ECMO indicates that in these patients, protective lung ventilation should be considered.

Long-term clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock according to the application and initiation time of extracorporeal membrane oxygenation in South Korea.

Limited data are available regarding the proper application time and long-term outcomes of extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock. This cohort study appraised the clinical outcomes according to ECMO application without or before cardiopulmonary resuscitation (CPR) in patients with acute myocardial infarction (AMI) combined with cardiogenic shock. Between 2011 and 2015, a total of 13,104 patients with AMI were enrolled in a nationwide AMI registry. Eligible patients with cardiogenic shock, who underwent percutaneous coronary intervention, with a 3-year clinical follow-up, were analyzed. The 949 included patients were divided into two groups: no ECMO (n = 845) and ECMO application (n = 104). The ECMO group was further divided into ECMO without or before CPR (n = 11) and ECMO after CPR (n = 93). Significant differences were noted in major adverse cardiac events (MACEs) between the no ECMO and ECMO application groups during the 3-year follow-up (41.5% vs. 80.8%; p < 0.001). However, the ECMO without or before CPR group showed similar outcomes to the no ECMO group in 3-year MACEs (63.6% vs. 41.5%; p = 0.055). MACEs during 3 years of follow-up were significantly lower in the ECMO without or before CPR group than in the ECMO after CPR group (63.6% vs. 82.8%; p = 0.005). A significantly lower risk of major cardiac events in ECMO without or before CPR suggests that early application of ECMO can be a reasonable strategy to improve outcomes in patients with AMI complicated by cardiogenic shock.

Using extracorporeal membrane oxygenation in donations after cardiac death or brain death: A single-center experience and long-term outcome.

The use of extended criteria donors is a routine practice that sometimes involves extracorporeal membrane oxygenation (ECMO) in donations after cardiac death or brain death. We performed a retrospective study in a single center from January 2006 to December 2019. The study included 90 deceased donor liver transplants. The patients were divided into three groups: the donation after brain death (DBD) group (n = 58, 64.4%), the DBD with ECMO group (n = 11, 12.2%) and the donation after cardiac death (DCD) with ECMO group (n = 21, 23.3%). There were no significant differences between the DBD with ECMO group and the DBD group. When comparing the DCD with ECMO group and the DBD group, there were statistically significant differences for total warm ischemia time (p < 0.001), total cold ischemia time (p = 0.023), and split liver transplantation (p < 0.001), and there was significantly poor recovery in regard to total bilirubin level (p = 0.027) for the DCD with ECMO group by repeated measures ANOVA. The 5-year survival rates of the DBD, DBD with ECMO, and DCD with ECMO groups were 78.1%, 90.9%, and 75.6%, respectively. The survival rate was not significantly different when comparing the DBD group to either the DBD with ECMO group (p = 0.435) or the DCD with ECMO group (p = 0.310). Using ECMO in donations after cardiac death or brain death is a good technology, and it contributed to 35.6% of the liver graft pool.

Venovenous Versus Venoarterial Extracorporeal Membrane Oxygenation: Pediatric Acute Respiratory Distress Syndrome.

This study aimed to compare the efficacy, complication, and mortality of patients who were supported by venovenous (VV) extracorporeal membrane oxygenation (ECMO) and venoarterial (VA) ECMO for pediatric acute respiratory distress syndrome (PARDS). This study is a single-center, retrospective cohort study between 2014 and 2022. We evaluated to indication of ECMO support, ECMO type, patients' demographic features, complications, and children's outcomes supported by ECMO for PARDS. Twenty-two patients with PARDS, 12 (54%) with VV, and 10 (46%) with VA ECMO were selected. The median number of days to be intubated before ECMO cannulation was 5 (0-16) days. The distribution of intubated days before the patients underwent ECMO was as follows: 0-1 days, 7 (31.8%) patients; 2-3 days, 2 (9.1%) patients; 4-7 days, 7 (31.8%) patients; 8-14 days, 5 (22.8%) patients; >14 days, 1 (4.5%) patient. The median ECMO cannulation day after admission to the pediatric intensive care unit was 3 (range, 1-9) days in the VV ECMO patient group, whereas it was 8 (range, 0-19) days in the VA ECMO group (P = .02). Considering hospital survival, 4 (45%) patients who underwent double-lumen VV ECMO, 1 (33%) patient who underwent VV ECMO, and 3 (30%) patients who supported by VAECMO survived. There was no difference between the groups in terms of hospital discharge rates. The highest survival rate was found in the VV ECMO patient group established with double-lumen cannulas, similar to the literature. There was no difference in mortality between the groups whose intubation time before ECMO was 14 days or less.