Extracorporeal Membrane Oxygenation Research Articles

Outcome of single-ventricle patients supported with extracorporeal membrane oxygenation

Background: Single ventricle heart disease can be left or right ventricle dominant congenital heart disease mostly associated with other risk factors like low birth weight, Preterm, chromosomal abnormality and all these risk factor associated with increase mortality. Methods: A retrospective chart review of paediatric patients from neonatal age to 14 years since 2012 to 2021, with supported by extracorporeal membrane oxygenation (ECMO) including both single ventricle heart physiology and biventricular heart, admitted in paediatric cardiac surgical intensive care unit in our hospital was conducted. All data were compared between single ventricle heart physiology and biventricular heart. Data was performed using commercially available software (SPSS), with statistical significance set p<0.05. Results: We enrolled total 124 patients who underwent ECMO cannulation. 68 children had single ventricle, while 56 being biventricular heart. Most children acquired ECMO cannulation in CICU 63 (50.8%). Male to female ratio was 74:50. 70.2% children got the ECMO cannulation when they had already been operated for surgical repair. Conclusions: Paediatric ECMO utilization in SV is valuable and recently its utilization has been increased in it with improve survival.

Survival of a Patient Following Initial LVAD Implantation and Two Successive LVAD Exchanges: case report

Abstract Background Initially conceptualized as a bridge to heart transplantation, the Left Ventricular Assist Device (LVAD) has become an important option for improving survival in patients with severe heart failure and poor prognosis. Case summary We report the case of a patient suffering from severe chronic heart failure, complicated by ST-elevation myocardial infarction (STEMI) due to left main coronary artery (LMCA) stenosis (NYHA IV, INTERMACS profile 1). Despite support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO), inotropes and catecholamine therapy, the patient´s cardiac function did not recover sufficiently. Consequently, the decision was made to proceed with LVAD implantation as destination therapy. The initial LVAD implantation was uneventful, and the patient received anticoagulant therapy according to standard operating procedure (SOP). However pump thrombosis occurred on the first postoperative day, necessitating an LVAD exchange. Following an extended stay in the cardiac surgery intensive care unit (ICU), the patient was eventually discharged. Approximately 15 months later, the patient developed a driveline infection, involving most of the intrapericardial components of the LVAD. A second LVAD exchange was required and the patient received a third LVAD. To mitigate the risk of recurrent infection, suppressive antibiotic therapy with ampicillin/sulbactam was initiated. Discussion This is the first reported case of a patient surviving three LVAD implantations and highlights an instance of off-label use of lifelong antibiotic therapy following a driveline infection.

Enhanced Hemodynamics of Anisometric TPMS Topology Reduce Blood Clotting in 3D Printed Blood Contactors.

Artificial organs, such as extracorporeal membrane oxygenators, dialyzers, and hemoadsorber cartridges, face persistent challenges related to the flow distribution within the cartridge. This uneven flow distribution leads to clot formation and inefficient mass transfer over the device's functional surface. In this work, a comprehensive methodology is presented for precisely integrating triply periodic minimal surfaces (TPMS) into module housings and question whether the internal surface topology determining the flow distribution affects blood coagulation. Three module types are compared with different internal topologies: tubular, isometric, and anisometric TPMS. First, this study includes a computational fluid dynamics (CFD) simulation of the internal hemodynamics, validated through experimental residence time distributions (RTD). Blood tests using human whole blood and subsequent visualization of blood clots by computed tomography, allow the quantification of structure-induced blood clotting. The results indicate that TPMS topologies, particularly anisometric ones, serve as effective flow distributors and significantly reduce and delay blood clotting compared to conventional tubular geometries. For these novel TPMS modules, the inner surfaces can be activated chemically or functionalized to function as a selective adsorption site or biocatalytic surface or made of a permeable material to facilitate masstransfer.

Clinical characteristics and long-term outcomes of Venoarterial extracorporeal membrane oxygenation in children with congenital heart disease.

To analyze the clinical outcomes of extracorporeal membrane oxygenation (ECMO) support in children with congenital heart disease (CHD) after surgery and explore the risk factors associated with mortality during long-term follow-up for 3-5 years. We conducted a retrospective observational study at Shanghai Children Medical Center (SCMC) from 2017 to 2021 and reviewed the clinical results and laboratory findings of 188 CHD patients who received ECMO support during this period. The 5-year overall survival rate was 56.38% (106/188) among CHD patients who received ECMO support. Kaplan-Meier curve showed residual anatomical malformation (RAM) (p < 0.0001), gastrointestinal bleeding (p = 0.019), single ventricular (SV) (p = 0.028), and pre-ECMO lactate level >10 mmol/L (p < 0.0001) were significantly associated with higher mortality in follow-up. Cox analysis identified RAM (p = 0.039) and pre-ECMO lactate level >10 mmol/L (p < 0.001) as independent risk factors for overall survival. Conversely, a minimum platelet count ≥50 × 109/L (p < 0.001) was found to be a protective factor. Moreover, a competing risk model showed that a CPR time ≥60 min (p < 0.001) was identified as a risk factor for death in patients who failed to be discharged from the hospital. Our study showed characteristics of long-term follow-up patients and revealed several risk factors associated with mortality in children with CHD who received ECMO support. These findings can provide valuable insights for clinical decision-making and contribute to improving patient outcomes.

Efficacy and safety of percutaneous post-closure technique during the decannulation for veno-arterial extracorporeal membrane oxygenation.

In recent years, during the decannulation process for veno-arterial extracorporeal membrane oxygenation (VA-ECMO), methods for suturing the femoral artery have included the pre- and post-closure techniques. The safety and efficacy of the pre-closure technique are widely recognised; however, reports on the post-closure technique are scarce. This study aimed to evaluate the safety and efficacy of the post-closure technique using ProGlide (Abbott Healthcare, Green Oaks, IL, USA) device during VA-ECMO decannulation. We reviewed 170 patients who underwent VA-ECMO between January 2021 and June 2023. All patients had their femoral artery puncture sites closed using the post-closure technique upon decannulation. The success rate of this technique and incidence of lower limb complications were recorded and analysed. Technical success was achieved in 157 (92.4%) patients. Sixteen patients (9.4%) experienced lower limb-related complications, including 8 (4.7%) with lower limb arterial thrombosis and 11 (6.5%) with pseudo-aneurysms. Among all lower limb-related complications, four patients (2.4%) required interventional procedures. This study included 170 patients: 80 in the 'S' (15-16F) group and 90 in the 'M' (17-19F) group. In the univariate analysis of different arterial cannula sizes for in-hospital lower limb-related complications, the differences were not statistically significant (p > 0.05). The multivariate logistic model indicated that, compared to the S (15-16F) group, the M (17-19F) group was not associated with an increased rate of in-hospital lower limb-related complications. The suture-mediated closure of the femoral artery during VA-ECMO decannulation is a promising therapeutic strategy.

Crossing-Borders: Experiences With International Transports on Extracorporeal Membrane Oxygenation: Special Considerations and Challenges

Extracorporeal membrane oxygenation (ECMO) is a crucial support for patients with severe cardiac or respiratory failure, but its availability is limited, often requiring patient transport to specialized centers. Only a few centers provide mobile ECMO services, and international ECMO transports are rare. This study reviews a department’s experience with international ECMO transports from 1998 to 2022. Out of 1,277 ECMO transports, 357 (28%) were international. Most of these (52%) were directed to ECMO Center Karolinska, whereas others involved transfers due to a lack of beds or between foreign centers. The majority (79%) of patients were cannulated at the referring hospital, with 63% supported by venoarterial ECMO. Transport distances averaged 1,200 km, using fixed-wing aircraft 89% of the time. Hospital survival for those transported to Karolinska was 82%, and 36% of transports experienced complications, though no deaths occurred during transport. This study highlights the safety and effectiveness of international ECMO transport with highly trained teams.

The development of a C5.0 machine learning model in a limited data set to predict early mortality in patients with ARDS undergoing an initial session of prone positioning.

Acute Respiratory Distress Syndrome (ARDS) has a high morbidity and mortality. One therapy that can decrease mortality is ventilation in the prone position (PP). Patients undergoing PP are amongst the sickest, and there is a need for early identification of patients at particularly high risk of death. These patients may benefit from an in-depth review of treatment or consideration of rescue therapies. We report the development of a machine learning model trained to predict early mortality in patients undergoing prone positioning as part of the management of their ARDS. Prospectively collected clinical data were analysed retrospectively from a single tertiary ICU. The records of patients who underwent an initial session of prone positioning whilst receiving invasive mechanical ventilation were identified (n = 131). The decision to perform prone positioning was based on the criteria in the PROSEVA study. A C5.0 classifier algorithm with adaptive boosting was trained on data gathered before, during, and after initial proning. Data was split between training (85% of data) and testing (15% of data). Hyperparameter tuning was achieved through a grid-search using a maximal entropy configuration. Predictions for 7-day mortality after initial proning session were made on the training and testing data. The model demonstrated good performance in predicting 7-day mortality (AUROC: 0.89 training, 0.78 testing). Seven variables were used for prediction. Sensitivity was 0.80 and specificity was 0.67 on the testing data set. Patients predicted to survive had 13.3% mortality, while those predicted to die had 66.67% mortality. Among patients in whom the model predicted patient would survive to day 7 based on their response, mortality at day 7 was 13.3%. Conversely, if the model predicted the patient would not survive to day 7, mortality was 66.67%. This proof-of-concept study shows that with a limited data set, a C5.0 classifier can predict 7-day mortality from a number of variables, including the response to initial proning, and identify a cohort at significantly higher risk of death. This can help identify patients failing conventional therapies who may benefit from a thorough review of their management, including consideration of rescue treatments, such as extracorporeal membrane oxygenation. This study shows the potential of a machine learning model to identify ARDS patients at high risk of early mortality following PP. This information can guide clinicians in tailoring treatment strategies and considering rescue therapies. Further validation in larger cohorts is needed.

Initial experience with pump controlled retrograde trial-off (PCRTO) veno-arterial extra corporeal membrane oxygenation in children.

Pump Controlled Retrograde Trial Off (PCRTO) is a relatively new technique in trialing-off Veno-Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO). Literature on the use of PCRTO in children remains scarce. We describe our centre's initial experience with PCRTO in a neonate and an older child and review its potential advantages and disadvantages compared to traditional weaning methods. More research and shared best practices are required in children to facilitate wider adoption of this technique.

Population Pharmacokinetics of Vancomycin in Intensive Care Patients with the Time-Varying Status of Temporary Mechanical Circulatory Support or Continuous Renal Replacement Therapy.

This study characterized the population pharmacokinetics (PK) of vancomycin in patients treated with and without continuous renal replacement therapy (CRRT) or temporary mechanical circulatory support (tMCS), including extracorporeal membrane oxygenation or extracorporeal ventricular assist device. Critically ill adults with and without tMCS or CRRT prescribed vancomycin were enrolled for population PK modeling. MonteCarlo simulation provided dosing recommendations based on the probability of target attainment (PTA), achieving a 24-h area under curve (AUC24h) of 400-600mg*h/L. Twenty-five patients with 184 plasma samples were analyzed. The median age was 61.0years. The final model was a two-compartment PK model. CRRT, serum creatinine, and body weight were significant predictors of clearance. CRRT was a covariate on the central volume of distribution. tMCS significantly decreased the intercompartmental clearance. The simulated mean trough levels at the 48th hour were lower in the tMCS group (13.4 versus 14.2mg/dL in non-tMCS, p < 0.001) in a 70-kg subject with a creatinine of 1mg/dL and a daily dose of 20mg/kg, but the PTA was similar (61.8% versus 62.2%). A reduction of maintenance dose from 30 to 10mg/kg/day with loading dose from 25 to 15mg/kg is recommended while serum creatinine progresses from 0.5 to 4.0mg/dL. For CRRT, the optimal regimen consists of 20-25mg/kg loading and maintenance of 15mg/kg/day. The dosing strategy of vancomycin can be based on body weight or renal function, regardless of tMCS. Intercompartmental clearance decreases under tMCS, which can mislead a dosing adjustment based on trough level.

Hypothermic cardiac arrest: prognostic factors for successful resuscitation before rewarming.

To indicate factors predicting return of spontaneous circulation in patients with hypothermic cardiac arrest in the pre-rewarming period. A multicenter retrospective study was conducted. We included patients who had suffered cardiac arrest caused by severe accidental hypothermia with a core body temperature of ≤ 28°C. Patients who had achieved return of spontaneous circulation before commencement of active rewarming at the hospital were compared to those who remained in cardiac arrest. A total of 156 patients suffering hypothermic cardiac arrest were included in the study. In 14 of them (9%) resuscitation was successful before rewarming. Factors associated with return of spontaneous circulation were as follows: witnessed onset of cardiac arrest (p = 0.04); a higher core body temperature (p = 0.005) with a prognostic threshold of 24.6°C; and a higher arterial oxygen partial pressure (p = 0.04) with a prognostic threshold of 81mmHg. One patient after successful resuscitation sustained recurrence of cardiac arrest during rewarming. Patients with core body temperature < 25°C, hypoxemia, and those who sustained unwitnessed hypothermic cardiac arrest have weak chances for successful resuscitation before rewarming. They can benefit from immediate transportation to an extracorporeal life support facility under continuous cardiopulmonary resuscitation. Effective rewarming and oxygenation during the prehospital period can increase the chances for return of spontaneous circulation. Recurrence of cardiac arrest during rewarming is uncommon.

Algorithm of High-Risk Massive Pulmonary Thromboembolism with Extracorporeal Membrane Oxygenation

Objective: Massive pulmonary embolism (PE) remains a life-threatening condition, often leading to acute respiratory and cardiac failure. This study evaluates the role of extracorporeal membrane oxygenation (ECMO) as a supportive treatment for high-risk patients undergoing surgical pulmonary embolectomy or catheter-based thrombectomy. Methods: Between January 2018 and December 2023, 27 patients with high-risk massive PE were treated at our center. Surgical embolectomy (n = 7) and catheter-based thrombectomy (n = 5) were performed, with ECMO support (veno-arterial [VA] or veno-arterial-venous [VAV]) initiated preoperatively, intraoperatively, or postoperatively, based on hemodynamic instability. ECMO was used as a bridge to recovery, and outcomes were assessed in terms of mortality, hemodynamic stabilization, and recovery. Results: Of the 27 patients, 20 were supported with ECMO, with 7 requiring VA-ECMO intraoperatively due to difficulties in weaning from cardiopulmonary bypass (CPB). Nine patients were later transitioned to VAV-ECMO due to Harlequin syndrome and persistent hemodynamic instability. The in-hospital mortality rate was 18.5% (n = 5), with survivors showing significant improvements in hemodynamic and biochemical parameters post-ECMO, including reduced lactate levels, improved right ventricular function, and the stabilization of mean arterial pressure. The mean follow-up time was 10.2 ± 3.9 months, with no late deaths or complications observed. Conclusions: ECMO provides effective life support in high-risk patients with massive PE who are undergoing surgical embolectomy or thrombectomy. It stabilizes hemodynamics, improves cardiac and pulmonary function, and facilitates recovery in critically ill patients. Further research is needed to refine patient selection, optimize ECMO timing, and assess long-term outcomes to determine its definitive role in the management of high-risk PE.

Utilizing metagenomic next-generation sequencing and phylogenetic analysis to identify a rare pediatric case of Naegleria fowleri infection presenting with fulminant myocarditis

BackgroundNaegleria fowleri (N. fowleri), a rare and typically lethal amoeba, most commonly causes primary amoebic meningoencephalitis (PAM). This case report describes an exceptionally rare presentation of fulminant myocarditis as the primary manifestation in a 6-year-old child, diverging from the typical neurological pathogenesis associated with N. fowleri infection. Beyond neurological afflictions, the child developed arrhythmias and cardiac failure, necessitating treatment with extracorporeal membrane oxygenation (ECMO).MethodsDiagnosis was confirmed via metagenomic next-generation sequencing (mNGS) of both blood and cerebrospinal fluid (CSF). This analysis not only substantiated the infection but also revealed a potential new genotype of N. fowleri, designated k39_3, suggesting broader genetic diversity than previously recognized.ResultsImmediate treatment with Amphotericin B (Am B) and rifampin was initiated upon diagnosis. Despite aggressive management and supportive care, the patient failed to maintain hemodynamic stability, continued to show a decrease in cardiac output, and exhibited relentless progression of central nervous system failure, culminating in death within 72 h.ConclusionOur report documents a rare pediatric case of N. fowleri infection presenting with fulminant myocarditis, revealing an unexpected clinical manifestation and broadening the known spectrum of its effects. This emphasizes the need for enhanced surveillance and targeted research to understand the pathogenic mechanisms and improve treatment strategies.

Hemodynamic Effects and Clinical Outcomes of Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation (LAVA-ECMO) in Cardiogenic Shock.

Left atrial veno-arterial extracorporeal membrane oxygenation (LAVA-ECMO) in CS is a novel mechanical cardiocirculatory support strategy that provides robust cardiocirculatory support and simultaneous left and right atrial venting via a multi-fenestrated transeptal catheter. We performed a single-center retrospective analysis of all patients aged ≥ 18 years with CS who underwent LAVA-ECMO at a quaternary care institution from 2018-2023. Clinical outcomes as well as pre- and post-hemodynamics were evaluated. A total of 68 patients were analyzed (75% male, 72% white, median age 63). Indications for LAVA-ECMO were CS due to myocardial infarction (29.4%), biventricular failure (26.5%), and/or valvular heart disease (26.5%). Trans-septal puncture was guided by intracardiac echocardiography (86.8%) or transesophageal echocardiography (13.2%). Arterial cannulation was performed via transcaval access in 25% of the cases. Post-LAVA-ECMO cannulation was associated with substantial improvement in the hemodynamics within 24 hours post cannulation, including reduction in right atrial pressure (absolute mean difference: -5.0 mmHg, p<0.001), mean pulmonary artery pressure (-9.0 mmHg, p<0.001), pulmonary capillary wedge pressure (-10.0 mmHg, p<0.001), and LV end-diastolic pressure (-14.0 mmHg, p<0.001). Survival to decannulation occurred in 69.1%, while 30-day survival from cannulation was 51.5%. In-hospital all-cause mortality was 51.5%. Only 5 patients (7.4%) required additional MCS (4 Impella, 1 VAV-ECMO). There were no complications related to transeptal placement of the venous ECMO cannula. In conclusion, LAVA-ECMO, a MCS strategy providing bi-atrial drainage, appears to also provide simultaneous LV venting as demonstrated by improved invasive hemodynamics. Although the procedure itself appears safe, with no direct complications to interatrial septal cannulation, post-cannulation complications remain high, and further studies are needed to evaluate the full safety profile of LAVA-ECMO compared to alternative MCS strategies.

Enhancing survival in cardiac arrest: The urgent need for optimized extracorporeal cardiopulmonary resuscitation implementation and protocols: Editorial

Extracorporeal CPR (ECPR) involves venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with sudden and unexpected pulse loss due to heart-stopping mechanical activity. ECPR in patients with cardiac arrest has been shown to significantly improve the prognosis. In emergency rooms, interdisciplinary coordination exists among emergency medicine, cardiology, critical care, and perfusion technology. However, some problems must be solved, such as excessive costs, resource allocation, and the need for specialized equipment. Resuscitation success and patient outcomes can be enhanced by combining ECPR and emergency care.

Abstract 4137942: Comparing Outcomes in Low versus High Activated Partial Thromboplastin Time-guided Anticoagulation Monitoring during Extracorporeal Membrane Oxygenation

Introduction: Systemic anticoagulation in Extracorporeal Membrane Oxygenation (ECMO) aims to reduce the risk of patient and circuit thrombosis, but requires monitoring due to risk of bleeding. Activated partial thromboplastin time (aPTT) is one of many tests utilized for this purpose. However, it lacks validation in ECMO patients and its clinical utility necessitates further analysis. Aim: We aim to elucidate associations between low versus high aPTT-guided anticoagulation monitoring and total time, survival, bleeding, and thrombotic events during ECMO. Methods: A retrospective review was conducted on 93 patients requiring ECMO at our institution between January 2020 and March 2021. Study inclusion required more than 2 days on ECMO and maintenance on anticoagulation with aPTT targets predominantly greater (&gt;) or less than (&lt;) 60 seconds (s). Final cohort was 74 subjects; 30 subjects with majority aPTT targets &lt;60s composed the control “low” aPTT group and 44 subjects with aPTT targets &gt;60s composed the “high” aPTT group. Primary outcomes were survival to decannulation, survival to discharge, average time on ECMO, and incidence of bleeding and thrombotic events during ECMO. Bleeding and thrombotic events were classified into subtypes and incidence of each was recorded. Statistical analyses were performed with Fisher’s exact, Pearson’s chi-square, and Student’s t-tests with an alpha level of .05 on IBM SPSS software. Results: The high group required a longer average time on ECMO (29.5 days versus 14.3 days; p = .002; 95% CI [5.5; 24.7]). Chi-square tests did not show an association between the low versus high groups and survival to decannulation (22/30 and 35/44; p = .533), survival to hospital discharge (17/30 and 30/44; p = .312), or overall incidence of bleeding (18/30 and 20/44; p = .219) and thrombotic events (7/30 and 14/44; p = .427). Regarding subtypes of events, Fisher’s exact test showed an association between aPTT target &gt;60s and severe epistaxis (1/30 in the low and 9/44 in the high group; two-tailed p = .042). Though not significant, a greater incidence of oxygenator failure and circuit thrombosis was recorded in the high group. Conclusions: Our findings did not establish a relationship between aPTT target &lt;60s or &gt;60s and survival, bleeding, or thrombotic events. However, aPTT target &gt;60s was associated with longer average ECMO time and severe epistaxis. Further investigation of aPTT-guided anticoagulation monitoring in ECMO patients is needed.

Abstract 4115816: Enhancing Cardiogenic Shock Management: Insights from MCS utilization and Patient Outcomes

Cardiogenic shock (CS) remains a challenge with high mortality rates despite advances in treatment modalities. This study investigates the utilization and impact of mechanical circulatory support (MCS) devices, including intra-aortic balloon pump (IABP), Impella, and Extracorporeal Membrane Oxygenation (ECMO) on patient outcomes in CS management. A retrospective analysis was performed using National Inpatient Sample data (2017 to 2019). Inclusion criteria included patients aged ≥18 years with primary diagnosis of CS using ICD10(R570). Multivariate regression analysis was used to assess MCS duration, mortality, length of stay (LOS), and costs. Among 462,685 included patients, 38% were female, with a mean age of 66 years. Majority were White (67%), followed by Black (16.5%), and Hispanic (9%). IABP was utilized in 13% of cases, Impella in 6%, and ECMO in 0.9%. No significant difference was observed in MCS placement between weekdays vs weekends. However, weekend admissions showed higher mortality rates with an odd ratio (OR) of 1.06(p &lt;0.00, CI 1.03-1.09), particularly among females OR 1.25(p&lt;0.00, CI 1.22 – 1.289). Urban non-teaching hospitals exhibited highest mortality rate, followed by Urban teaching. ECMO was associated with highest mortality OR 2.08(p &lt; 0.00, CI 1.93-2.82), followed by Impella OR of 1.47 (p &lt; 0.00, CI 1.37 – 1.59), and IABP OR 0.723 (p &lt; 0.00, 0.685-0.765). LOS was lowest in Impella group, followed by IABP, while ECMO showed non-significant LOS increase. Mean total charge varied among MCS groups with ECMO being highest. The findings highlight several important aspects of CS management. Elevated mortality rates during weekend admissions suggest potential disparities in care access or delivery, necessitating investigation and interventions to ensure consistent quality of care throughout the week. Increased mortality among females, variations across different hospital settings, impact of MCS devices on LOS and costs emphasize the need for tailored approaches to enhance patient outcomes and resource utilization efficiency.

Abstract 4129945: Risk of stroke for AMI treated with temporary mechanical circulatory support: ten-year data from National Inpatient Sample

Objectives: The aim of this study was to assess the risk of stroke for temporary mechanical circulatory support (tMCS) device treated acute myocardial infarction (AMI). Background: Data are limited regarding risk of stroke for temporary mechanical circulatory support (tMCS) device treated acute myocardial infarction (AMI). Methods: The national inpatient sample database was analyzed to identify adults who were hospitalized for AMI between 2012 and 2021, hospitalizations were grouped based on the temporary mechanical circulatory support device. Study design: In the final cohort, there are 8,272,163 (96.0%) weighted hospitalizations treated without tMCS, 265,870 (3.1%) with Intra-Aortic Balloon Pump (IABP) alone, 59,240 (0.7%) with Impella alone, and 16,225 (0.2%) with Extracorporeal Membrane Oxygenation (ECMO) used during the hospitalization. Results: The overall stroke rates for patients who treated without tMCS, IABP alone, Impella alone, and ECMO group were 3.41%, 3.46%, 4.51%, and 13.34% respectively. Specifically, the rates of ischemic stroke for these groups were 2.95%, 3.12%, 3.96% and 10.11% respectively. The rates for hemorrhagic stroke were 0.68%, 0.55%, 0.81%, and 4.90% for the same groups. In the stepwise forward Cox regression analysis, the adjusted OR (aOR) of ECMO use for overall stroke was 3.04 (95%CI [2.66-3.48]), followed by Impella only use with an aOR of 1.79 (95%CI [1.61-2.00]), and atrial fibrillation (aOR 1.34, 95%CI [1.31-1.38]). The subgroup analysis revealed that hospitalization with age younger than 50 years old, those without hypertension, and those presented with ST-elevation myocardial infarction are at particularly high risk of stroke for ECMO treated AMI. Conclusion: This ten years AMI hospitalizations analysis revealed that ECMO and Impella treatment associated with increased risk of both ischemic and hemorrhagic stroke. Particularly for those younger than 50, those without hypertension, and those presented with ST-elevation myocardial infarction. However, treatment with IABP alone does not increase the risk of stroke.

Abstract 4135360: Eosinophilic Myocarditis: An Atypical Presentation with a Labile Course: A Case Report

Case presentation: A 64-year-old man presented with one day of chest pain. Initial evaluation showed elevated cardiac enzymes (CE) and normal eosinophil count. Electrocardiogram (EKG) was unremarkable. Transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 40% and a moderate-large pericardial effusion with signs of tamponade. Pericardiocentesis was deferred due to the lack of a safe window. Left and right heart catheterization showed no occlusive disease or chamber pressure equalization. The patient developed worsening shock, raising suspicion for myocarditis and prompting an endomyocardial biopsy (EMB). He was placed on extracorporeal membrane oxygenation (ECMO) on day 3. The EMB resulted as eosinophilic myocarditis (EM), and high dose Methylprednisolone was started. He was decannulated from ECMO on day 10. Intra-operative transesophageal echocardiogram (TEE) post-decannulation showed a normal EF without segmental abnormalities. Three hours later, a rise in CEs was noted, and EKG showed ST elevations inferiorly. TTE showed a reduced EF with multiple segmental abnormalities concerning for myocardial infarction. A repeat coronary angiogram was unremarkable. Due to the residual pericardial effusion, the patient underwent a pericardial window draining 200 cc of serosanguinous fluid. Intra-operative TEE showed an EF of 20% with no improvement after drainage. He had a cardiac arrest during the procedure and was placed back on ECMO. High-dose steroids were resumed along with intravenous immunoglobulin. Despite interventions, the patient continued to deteriorate and he ultimately expired. Discussion: EM has high mortality and a variable course, often requiring EMB for diagnosis. As in our case, about 25% of cases present without peripheral eosinophilia. Pericardial effusion occurs in 34% of cases and tamponade in 6%. A distinct feature of this case is the decompensation associated with ST elevation and segmental abnormalities, thought initially to be myocardial infarction (MI), after an initial response to steroids. While the etiology of such decompensation is unclear, relapsing EM in the setting of tapering steroids is one explanation, as myocarditis and MI can share similar clinical features. Another explanation is cardiac tamponade, which has also been reported to mimic MI and myocarditis. Air embolism from ECMO decannulation is another possibility, though air embolisms may include cerebrovascular pathology, which was not observed.

Abstract 4134712: Pheochromocytoma-Induced Cardiomyopathy Requiring Mechanical Support with Ejection Fracture Recovery Following Surgical Resection

Introduction: Pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the adrenal medulla. The annual incidence is approximately 0.8 per 100,000 persons, though this is an underestimate given a high percentage diagnosed at autopsy. Classically, patients present with episodic headache, sweating, and tachycardia, however, pheochromocytomas can be associated with cardiomyopathy secondary to the catecholamine excess. We present an unusual case of pheochromocytoma-induced cardiogenic shock highlighting an excellent use of mechanical circulatory support with Impella and Extracorporeal Membrane Oxygenation (ECMO) bridging to surgical intervention resulting in left ventricular ejection fraction (LVEF) recovery. Case Description: A 49-year-old female with past medical history of asthma initially presented to an outside hospital for palpitations, chest pain, and hypertension. Transthoracic echo (TTE) showed preserved left ventricle ejection fraction (LVEF) while cardiac MRI showed a LVEF of 43% with dilated left ventricle and diffuse global hypokinesis consistent with a dilated cardiomyopathy. She underwent a coronary angiogram demonstrating nonobstructive CAD. She was then discharged with readmission a month later at our hospital for chest tightness, palpitations, vomiting, weakness, and dizziness. Repeat TTE showed a drop in LVEF to 10-15%. She progressed to cardiogenic shock requiring BiPAP and inotrope initiation, with progressive shock and hypotension ultimately requiring Impella 5.5 and venoartrial ECMO. Abdominal imaging was notable for 4.7 x 4.2 cm right adrenal nodule and further workup with serum and urine metanephrines confirmed pheochromocytoma. While supported, the patient underwent right adrenalectomy with subsequent wean of mechanical circulatory support and biventricular recovery on TTE. Discussion: Pheochromocytoma-induced heart failure is a rare but potentially life-threatening complication from excess catecholamine effects on the myocardium. Pheochromocytomas should be considered in the evaluation of idiopathic heart failure even in the absence of symptoms related to catecholamine excess. Early detection, pharmacological management, and surgical resection may prevent progression of myocardial remodeling. Mechanical circulatory support can be a valuable adjunct in managing refractory heart failure in these patients by providing temporary hemodynamic stabilization while awaiting definitive tumor resection.

Abstract Su701: The Influence of Public Assistance Among Patients Who Received Extracorporeal Cardiopulmonary Resuscitation after Cardiac Arrest in Japan

Background: This study aimed to evaluate the influence of public assistance on patients with out-of-hospital cardiac arrest (OHCA) who received extracorporeal cardiopulmonary resuscitation (ECPR) in Japan. Methods: We conducted a secondary analysis of data from the SAVE-J II study, a retrospective, multicenter registry study involving 36 participating institutions in Japan. Patients with cardiac arrest who received ECPR were divided into two groups depending on whether or not they had received public assistance. The primary outcome was 30-day survival. Secondary outcomes were as follows: 30-day favorable neurological outcomes (cerebral performance category scores 1-2); survival at discharge; favorable neurological outcome at discharge; number of intensive care unit, hospital, ventilator, and extracorporeal membrane oxygenation days; medical expenses; proportion of percutaneous coronary intervention; target temperature management; mechanical circulatory support (MCS) device use; and withdrawal of life-sustaining therapy. Results: Of 2,157 patients registered in the SAVE-J II study, 1,885 patients were enrolled in this study; 99 patients (5.3%) received public assistance and 1,786 patients (94.7%) did not. Multivariable logistic regression analysis did not show a significant difference in 30-day survival (OR 1.22, 95% CI 0.77-1.95, p=0.40). The log-rank test for the Kaplan-Meiercurve on 30-day survival did not demonstrate a significant difference (p=0.46). Except for the use of MCS devices, there were no significant differences in secondary outcomes. Conclusions: The use of public assistance did not influence the prognoses of OHCA patients receiving ECPR. Treatment option during hospitalization may be affected by the use of public assistance.