Disparities in Access to Neonatal and Pediatric Extracorporeal Membrane Oxygenation Services in the United States.

Transcatheter aortic valve replacement at metropolitan teaching hospitals among patients with heart failure.

Predictors of device-related adverse events in patients with intra-aortic ballon pump or microaxial flow pump for cardiogenic shock.

We have evaluated the complications and outcomes of venovenous multisite (VVMS) cannulation for support with extracorporeal membrane oxygenation (ECMO) using the Extracorporeal Life Support Organization (ELSO) registry of neonates (≤ 28 d old) and infants (29-364 d old). Retrospective ELSO database cohort, comparing outcomes and complications associated with VVMS and venovenous dual lumen (VVDL) cannulation. Patients younger than 1 year supported with VV ECMO. ELSO data January 1, 2013 to December 31, 2023. None. We identified 1403 neonates and 603 infants supported with VVDL, and 42 and 77, respectively, with VVMS. At 24 hours of ECMO we found median (interquartile range [IQR]) oxygen saturations (Sao2) were higher in the VVMS compared with the VVDL group: for neonates, 98% (IQR, 93-99%) vs. 94% (IQR, 89-97%); a p value of less than 0.01; and for infants, 94% (IQR, 91-97%) vs. 90% (IQR, 85-95%); a p value of less than 0.01. After adjustment for ventilatory parameters, VVMS was associated with higher mean (95% CI) Sao2 than VVDL: for neonates by 3.3% (95% CI, 1.0-5.6%); p = 0.005; and for infants by 3.3% (95% CI, 1.3-5.3%); p = 0.002. Higher Sao2 was also associated with higher flows rather than ventilator parameters. Median flows were higher in the VVMS group compared with VVDL for neonates (111 vs. 101 mL/kg/min) and infants (114 vs. 100 mL/kg/min); a p value of less than 0.01. In general, we failed to identify associations between support technique and mortality or complications. However, in infants, VVMS in comparison with VVDL was associated with fewer mechanical complications (23% vs. 37%; p = 0.02). Between 2013 and 2023, in neonatal and infant ECMO, VVMS as opposed to VVDL cannulation was associated with higher ECMO flows and Sao2 at 24-hour support. We failed to identify associations between support technique and complications or mortality, apart from lower mechanical complications in infants supported using VVMS.

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.

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%.

Objective: To explore the efficacy of the implementation of quality control (QC) program for children with fulminant myocarditis (FM) on improving the survival rate, reducing mortality and complication rates, and to evaluate the feasibility of the QC protocol. Methods: A retrospective cohort study was conducted. A Clinical Medical Quality Control Scoring Scale for Pediatric Fulminant Myocarditis (the QC Scale) was implemented since January 2021. Clinical data and the QC Scale data of 187 children with FM admitted to 8 tertiary hospitals capable of pediatric extracorporeal membrane oxygenation (ECMO) treatment over 6 years were collected, including the pre-QC group (January 2018 to December 2020) and the post-QC group (January 2021 to December 2023). Independent-samples t-test, Mann-Whitney U test, Chi-square test or Fisher's exact test were used for intergroup comparisons; and multivariate Logistic regression was performed for risk factor analysis. The clinical characteristics of pediatric FM and the feasibility and clinical efficacy of the QC protocol were evaluated. Results: A total of 187 children with FM were enrolled, including 82 cases in the pre-QC period and 105 cases in the post-QC period. The age was (8±4) years, and the weight was (28±14) kg. There were 104 female cases (55.5%) and 83 male cases (44.5%). A total of 156 children survived and 31 died, with an overall in-hospital mortality rate of 16.6% (31/187). The completion rates of electrocardiogram or cardiac monitoring and echocardiography or non-invasive hemodynamic monitoring within 30 min after admission were 98.7% (81/82) and 92.6% (72/82) in the pre-QC group, compared with 96.2% (101/105) and 90.5% (95/105) in the post-QC group. The post-QC group showed significantly higher completion rates of blood lactate measurement and Glasgow Coma Scale assessment within 60 min of admission than the pre-QC group (86.5% (71/82) vs. 98.1% (103/105), 62.2% (51/82) vs. 81.9% (86/105), χ²=9.43, 8.72; P=0.002, 0.003). The pre-QC completion rates of reaching blood lactate ≤5 mmol/L, central venous oxygen saturation ≥65%, and urine output≥1 ml/(kg·h) at 12 h after treatment were 82.1%(46/56), 72.1%(31/43) and 72.7%(48/66), respectively, compared with 81.1%(77/95), 69.1%(47/68) and 80.9%(76/94) in the post-QC group. The time from admission to ECMO initiation was shorter in the post-QC group than in the pre-QC group ((11±17) vs. (7±10) h, t=2.09, P=0.037). The mortality rates were 22.0% (18/82) in the pre-QC group and 12.4% (13/105) in the post-QC group. Compared with the pre-QC group, the post-QC group presented decreased rates of pre-ECMO cardiopulmonary resuscitation, cerebral injury and severe renal injury (51.2% (42/82) vs. 28.6% (30/105), 19.5% (16/82) vs. 8.6% (9/105), 19.5% (16/82) vs. 8.6% (9/105); χ²=9.97, 4.76, 4.76, all P<0.05). Conclusions: The implementation of the QC protocol for pediatric FM improves the ability of organ injury identification and standardized treatment, facilitates timely ECMO initiation, reduces the occurrence of cardiac arrest and major complications, and is of great significance for improving long-term quality of life. The pilot hospitals achieves high completion rates of QC indicators, indicating good feasibility of the protocol.

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.

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.

To evaluate our "before vs. after" change in practice of stopping routine surveillance cultures in pediatric patients supported with extracorporeal membrane oxygenation (ECMO), by examining patient outcomes, reviewing antimicrobial prescription, and costs. Retrospective before vs. after study. PICU, neonatal ICU, and cardiac ICU in a quaternary children's hospital. Critically ill patients younger than 18 years supported on ECMO between October 2022 and March 2025. None. Patients supported on ECMO in the 12 months following the practice change in March 2024 were compared with the same number of ECMO patients from before the practice change (47 in each group). Removal of routine daily blood culture and every-other-day urine and respiratory culture orders in ECMO order sets was associated with a reduction in cultures obtained: from mean ( sd ) 1.8 (± 0.22) to 0.4 (± 0.19) per ECMO day ( p < 0.0001). We failed to identify an associated change in average ECMO run duration (211 vs. 181 hr; p = 0.48) or 30-day mortality (15/47 vs. 15/47). There was an associated decrease in antimicrobial prescriptions, quantified as a percentage of all ECMO days with prescription: (366/414 [88%] vs. 247/356 [69%]; mean difference, 19% [95% CI of the difference 13-25%]; p = 0.002). We estimate that using 2024 prices, there was a cost reduction of $136,000 in the 12 months following the change in practice. Our experience of introducing in March 2024 a change in using surveillance or scheduled cultures in pediatric ECMO patients in our center is that there was an associated reduction in microbiology cultures, improved antimicrobial stewardship, and cost-savings. In comparison with our experience before the change in practice, we failed to identify any associated negative effects such as increased duration of ECMO support or 30-day survival.

Extracorporeal membrane oxygenation (ECMO) provides lifesaving support for patients with cardiopulmonary failure but poses complex ethical challenges that may generate moral distress for clinicians, patients, and families. We convened a multidisciplinary panel of experts in cardiothoracic surgery, critical care, and palliative medicine to identify recurring ethical issues. The panel includes ECMO specialists working in the US, Canada, and the UK. The panel was nominated by organizers of a national critical care meeting. We analyzed four domains of ethical tension: 1) equitable ECMO candidacy decisions; 2) integration of palliative care and clinical ethics; 3) preservation of patient autonomy when institutional or benchmarking pressures influence care; and 4) responding to requests to continue ECMO when there is no exit strategy. Consensus recommendations emphasize transparent, team-based decisions, early involvement of ethics and palliative care, and consistent processes for ongoing review of candidacy and continuation of ECMO. Programs should recognize and mitigate institutional pressures that may undermine patient-centered care. As ECMO use expands, the development of ethical care frameworks is essential to ensure equity, uphold autonomy, and align treatments with patients' goals and values. This work provides a practical, consensus-based guide for addressing the ethical complexities of ECMO in contemporary critical care.

Extracorporeal Membrane Oxygenation (ECMO) serves as a temporary life support for critically ill patients, and with its advancing clinical application, survival rates have significantly improved. However, research focus is shifting from saving lives to improving survivors' quality of life. Currently, most studies concentrate on short-term outcomes such as in-hospital mortality, while long-term psychosocial adaptation after discharge remains understudied. Extracorporeal Membrane Oxygenation patients often face psychological distress during Intensive Care Unit stays and multiple challenges after discharge, which can profoundly affect their long-term quality of life and social reintegration. Therefore, it is necessary to conduct an in-depth study on the psychosocial adaptation of ECMO survivors and its influencing factors. To assess the long-term psychosocial adaptation status of survivors after Extracorporeal Membrane Oxygenation (ECMO) and to identify its key influencing factors. A multicentre cross-sectional study. This study utilized a convenience sampling method to recruit 205 patients discharged after Extracorporeal Membrane Oxygenation treatment from three tertiary hospitals, China. Data were collected using the Self-Report Psychosocial Adjustment to Illness Scale, general information questionnaire, the Connor-Davidson Resilience Scale and the Social Support Rating Scale. A total of 205 ECMO patients were included in this multicentre study. The psychosocial adaptation score of Extracorporeal Membrane Oxygenation patients was 48.40 ± 22.43. Multiple linear regression analysis revealed that age, income, residence, education level and time since discharge were significant influencing factors for psychosocial adaptation in these patients. The psychosocial adaptation of Extracorporeal Membrane Oxygenation patients was found to be at a moderate level, indicating a need for further improvement. Healthcare professionals should implement targeted interventions to enhance their psychosocial adaptation and promote better disease outcomes. For clinical nurses, these findings highlight the need to systematically assess not only patients' physical function but also their psychological resilience and ability to utilise social support during follow-up. Targeted interventions focusing on resilience-building and actively coaching patients on how to effectively seek and accept support should be integrated into post-ECMO care plans to improve long-term psychosocial adaptation. For patients and families, this underscores the importance of developing skills to actively engage with support networks and resources throughout the recovery journey.

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.

Every second counts: Association between activated clotting time and neurologic injury in neonatal ECMO.

State and Regional Variation in Access to Pediatric Extracorporeal Membrane Oxygenation.

Patients supported with extracorporeal membrane oxygenation (ECMO) frequently require prolonged, high-intensity analgosedation because of neuromuscular blockade, pain related to procedures, and pharmacokinetic alterations. These exposures increase the risk of iatrogenic medication toxicity and withdrawal. We evaluated whether buprenorphine (BUP) use during ECMO reduced full agonist opioid exposure and improved sedation compared with matched comparators. Using a retrospective matched case-control cohort design among ECMO patients in a cardiovascular intensive care unit, we contrasted 30 patients treated with BUP versus 30 comparator patients not treated with BUP (NO-BUP) matched using an a priori deterministic hierarchy. Comparisons were anchored to two matched time points: (i) the day before BUP exposure and (ii) the day after attaining the full therapeutic BUP dose; NO-BUP comparators were assessed on the analogous ECMO days. The primary outcome was the between-group difference in change in daily intravenous morphine milligram equivalents (MME) across this time period. Each cohort included 27 venovenous and three venoarterial ECMO patients. Demographics and illness severity did not differ between groups. Groups significantly differed in MME change scores (p < 0.001) with the BUP cohort decreasing significantly (p < 0.001) from 184.1 (interquartile range [IQR] 70.2-367.2) to 0.0 (IQR 0.0-11.6) median MME whereas NO-BUP comparators nonsignificantly decreased (p = 0.517) from 230.8 (IQR 153.3-567.0) to 177.2 (IQR 85.3-663.1). Groups also differed (p = 0.031) in time in target RASS range (-2 to 0); the BUP cohort significantly improved from 53.9% to 91.2% (p < 0.001) whereas NO-BUP comparators nominally improved from 37.8% to 46.1% (p = 0.275). In the BUP cohort, there was no precipitated withdrawal, opioid-induced constipation, or respiratory depression. Rates of tracheostomy, mortality, and extubation before decannulation did not differ significantly. BUP initiation among ECMO patients was feasible and associated with a marked reduction in full agonist opioid exposure and improved light-sedation target attainment. These findings are hypothesis-generating given the retrospective design and potential residual confounding.

15-Year Experience with Extracorporeal Membrane Oxygenation as Bridging Tool to Lung Transplantation: Risks, Opportunities, and Outcomes in a High-Volume Centre

Extracorporeal Membrane Oxygenation as a Bridge to Heart and Combined Heart - Lung Transplantation

Extracorporeal Membrane Oxygenation During Lung Transplantation Reduces Markers of Lung Injury in the Airspace

From battlefield to bedside: How military surgeons advanced pediatric critical care transport and ECMO.