Perfusion

Blood Stream Infections (BSI) occur in 3-35% of patients on ECMO (Extracorporeal membrane Oxygenation). With the increased use of ECMO since the COVID-19 pandemic, the magnitude of this problem has increased. There are no clear established practice guidelines for BSI prevention on ECMO.

Single center retrospective study. Data collected for adult and pediatric ECMO patients between the ages of 0-82 years between January 2017 – December 2023. Outcomes from patients before and after we implemented our ECMO-specific BSI prevention bundle in February 2021. This bundle includes two person ECMO cannula and central line dressing changes, daily chlorhexidine (CHG) bathing of the entire tubing of the ECMO circuit, including the hubs and connectors and avoiding prophylactic antibiotic use.

142 admissions for ECMO and ECPR during the study period were evaluated. 110 admissions were finally included for data analysis after 32 met exclusion criteria. 47 patients included from the preintervention and 63 in the post-intervention periods. The difference in BSI per admission between the preintervention and postintervention groups was statistically significant (p = .0003). The mean BSI rate was 0.468 in the preintervention group and 0.0159 in the post intervention group. Mortality showed a trend towards statistical significance (p = .082). There were no statistical differences in age, sex of the patient, body mass index (BMI), CRRT/AKI use/incidence, type of ECMO (VV or VA), presence of COVID-19 infection, and duration of ECMO.

The introduction of an ECMO-specific BSI reduction bundle resulted in a greater than 10-fold reduction in BSI. There was a trend towards statistically significant improvement in mortality between the two groups. We believe that this intervention is implementable at other hospitals.

The platelet trigger at which to transfuse platelets to prevent bleeding complications in patients supported with extracorporeal membrane oxygenation (ECMO) is unclear. We aimed to elucidate the association between platelet count and bleeding sequelae in this patient population.

We conducted a single-center retrospective study of all adult patients who received ECMO support from 2017 to 2022. Patients were stratified into two groups: “non-thrombocytopenic” (>30 × 10³ cells /μL) versus “thrombocytopenic” (≤30 × 10³ cells /μL). Multivariable logistic regression was used to determine the association between thrombocytopenia and bleeding complications; covariates were selected a priori. A post-hoc analysis investigating platelet transfusion status and nadir platelet count as an ordinal variable was also performed.

Of 291 VV- and VA-ECMO patients, 69 (24%) were categorized as “thrombocytopenic” and 144 (50%) experienced at least one major bleeding event. Compared to “non-thrombocytopenic” patients, “thrombocytopenic” patients were more likely to be male (p = 0.049), to require veno-arterial central canulation (p < 0.001), and to have been on dialysis (p < 0.001). Confounded by a 72% prophylactic transfusion rate, “Thrombocytopenia” was not associated with an increased risk of major bleeding (aOR: 0.59 [95% CI: 0.31–1.10]). However, in patients with a nadir platelet count between 31 and 50 × 10³ cells/μL, the 63% with a prophylactic platelet transfusion had a significant reduction in major bleeding complications (p = 0.003).

Our findings suggest that a platelet transfusion trigger of ≤50 × 10³ cells/μL is of benefit for prophylaxis against bleeding during ECMO support.

Bleeding and thrombosis are major causes of morbidity and mortality in pediatric extracorporeal membrane oxygenation (ECMO), yet their evolving, time-dependent risks remain poorly defined. This study evaluated clinical predictors of bleeding and thrombotic events using time-to-event analysis.

A retrospective cohort study was conducted using the Pediatric ECMO Outcomes Registry (PEDECOR) from October 2011 to September 2024. Patients aged ≤18 years undergoing their first ECMO run were included. Two time-varying Cox proportional hazards models assessed associations between prior complications and time to first bleed or thrombosis, adjusting for clinical and ECMO-related variables.

Among 1444 patients, median age was 0.4 years (IQR: 0.0–4.4), and 53.6% were male. Bleeding occurred in 65% and thrombosis in 28%. Time to first bleeding events had a median of 2 days (IQR: 0–4) while time to first thrombosis had a median of 3 days (IQR: 2–6). Prior thrombosis was associated with lower early bleeding risk (HR: 0.39, 95% CI: 0.25–0.62, p < 0.001), which reversed over time (interaction HR: 1.44, 95% CI: 1.08–1.92, p = 0.013; crossover at 12.4 days). Similarly, prior bleeding was associated with reduced early thrombosis risk (HR: 0.49, 95% CI: 0.34–0.71, p < 0.001), but reversed over time (interaction HR: 1.63, 95% CI: 1.26–2.11, p < 0.001; crossover at 4.3 days). Central cannulation, cardiac surgery, and non-pulmonary indications were associated with bleeding; sepsis was associated with thrombosis. Anticoagulant type and sex were not significant.

Bleeding and thrombosis are common and time-dependent in pediatric ECMO. These findings support dynamic anticoagulation strategies tailored to evolving risk.

The increasing need for high-quality training in Extracorporeal Life Support (ECLS) has highlighted the importance of simulation-based educational programs. The EduCorner, a key component of the EuroELSO conference since 2012, provides a platform for hands-on ECLS simulation, focusing on both technical and team-communication competencies.

This study evaluates the effectiveness of the EduCorner sessions conducted during the 12^th EuroELSO Conference in Krakow, Poland, assessing their impact on the participants’ ECLS knowledge and skills.

A total of 45 adult and pediatric ECLS simulation sessions were conducted, covering various topics such as ECLS troubleshooting, sepsis management, and ultrasound-guided cannulation. Pre- and post-session assessments were collected from participants to measure changes in their confidence, familiarity with ECLS procedures, and ability to work within a team. The data were analyzed using paired t-tests, descriptive statistics, and linear mixed-effects models.

The results revealed significant improvements in participants’ knowledge and competencies across various ECLS-related topics. Key areas of improvement included ECLS troubleshooting (p = .001), sepsis management (p = .022), and teamwork dynamics (p < .001). However, there was no significant change in familiarity with the ECLS circuit. Participants, especially those with prior exposure to the EduCorner, demonstrated notable increases in confidence and proficiency.

The EduCorner proved to be an effective educational platform for enhancing ECLS training, significantly improving both technical and non-technical skills. This study highlights the value of international simulation-based training in improving ECLS practice across multidisciplinary teams. Future initiatives should continue to foster collaboration between industry partners and congress organizers to maintain the quality and sustainability of such educational programs.

Bicuspid aortic valve (BAV) is a common congenital cardiac malformation associated with significant morbidity, including aortic dissection and thoracic aortic aneurysms. The mechanisms underlying BAV-associated aortopathy are unknown. We aimed to identify methylation profiles in BAV patients with aortopathy and investigate associated genetic pathways.

Tissue samples from the ascending aorta were obtained from BAV patients undergoing thoracic aortic surgery. DNA methylation profiles were measured using Illumina human 850K array. Probe methylation associations were reviewed, and a regression model assessed associations with aortic dimension.

Eight patients were recruited from University Hospital Southampton. Analysis revealed HEATR5A, PHLDB2, ADAMTS17, BID, and TLK1 as significantly associated genes. These genes were implicated in aortic wall remodelling through novel mechanisms identified by an unbiased, integrated epigenomic approach.

This study provides novel insights into epigenetic regulation in BAV-associated aortopathy. Identified genes, including HEATR5A, PHLDB2, ADAMTS17, BID, and TLK1, may contribute to aortic disease in BAV patients. Further research is needed to elucidate their mechanisms and therapeutic potential. Our findings improve understanding of the molecular basis of BAV-associated aortopathy and may inform future diagnostic and therapeutic strategies.

To assess whether prone positioning (PP) increases bleeding risk compared to supine positioning in ARDS patients undergoing veno venous Extracorporeal Membrane Oxygenation (VV ECMO).

A single-center retrospective observational study was conducted between January 2012 and March 2023. Data were systematically collected from an institutional ECMO registry, including baseline characteristics, daily variables, bleeding events, and outcomes. We compared the relative risk (RR) and incidence rate ratio (IRR) of bleeding between ‘Prone' and ‘Supine' patients. Bleeding-free days were analyzed using Kaplan-Meier curves and the Log-Rank test.

We included 136 consecutive severe ARDS patients undergoing VV ECMO (65% male, age 52 ± 11, 53% bacterial pneumonia), with 85 (62%) and 51 (38%) in the ‘Prone’ and ‘Supine’ group respectively. Bleeding occurred in 79 (58%) patients, with 43 of these being major bleeding events, including 14 intracranial hemorrhages. Fifty-two (61%) ‘Prone’ patients versus 27 (53%) ‘Supine’ patients had bleeding (RR 1.11 (95% CI: 0.81–1.52), p = .44; IRR 1.08 (95% CI: 0.68–1.75), p = .75), with a tendency towards lower major bleeding incidence in the ‘Prone’ versus ‘Supine’ patients (IRR 0.54 (95% CI: 0.29–1.03), p = .06). Kaplan-Meier survival analysis showed no significant difference in bleeding-free days between the ‘Prone’ and ‘Supine’ groups (p = .11).

PP during VV ECMO for ARDS was not associated with an increased incidence of bleeding. Further prospective studies are warranted to confirm these findings.

Air leak is a common complication of necrotizing pneumonia in critically ill children. Severe air leaks impact effective oxygenation and ventilation, oftentimes necessitating multiple thoracostomy tubes and extracorporeal support. Endobronchial valves (EBV) are a minimally invasive intervention to control air leak that may expedite de-escalation of care for critically ill children with necrotizing pneumonia.

A retrospective case series was conducted on patients at the Children's Hospital of Philadelphia who were hospitalized in the pediatric intensive care unit, required extracorporeal membrane oxygenation (ECMO), and underwent placement of one or more EBVs for air leak from July 2023 through August 2024.

Six patients, median age 12 years (range 18 months to 18 years), were hospitalized for necrotizing pneumonia complicated by severe air leak and required ECMO. The most common etiology was a viral infection with bacterial co-infection. The median number of EBVs placed per patient was five. The median total time on ECMO was 10 days, with a median duration of 3.5 days after valve placement. The median duration of antibiotic therapy was 47 days (range 24 to 126 days). One patient had a contralateral pneumothorax after valve placement, and another died due to progression of multiorgan failure that began before EBV placement. The five surviving patients were discharged from the hospital, weaned from all respiratory support, and their valves were removed without complication.

Endobronchial valves are a feasible intervention for severe air leak in critically ill children with necrotizing pneumonia and may expedite liberation from ECMO.

Postoperative delirium affects up to 60% of cardiac surgical patients. No reliable gold standard method exists for preventing delirium after cardiac surgery. An example of patient-personal monitoring is cerebral autoregulation (CA). This study aims to highlight the personal monitoring of patients’ cerebral autoregulation and to determine its relationship with postoperative delirium. Additionally, it seeks to test the hypothesis that the duration of CA impairment influences the onset of postoperative delirium.

A prospective study was conducted in 2021–2023. After approval of the Ethics Committee and with the patient’s written consent, 104 adult patients undergoing elective coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) surgery were enrolled. To diagnose possible delirium, all patients underwent a Confusion Assessment Method for the Intensive Care Unit (CAM–ICU) test. CA monitoring using transcranial Doppler was performed. CA status index – Mx was recorded.

Our study found that 12.5% of patients were diagnosed with delirium after on-pump CABG surgery. The total duration of cerebral autoregulation impairment (TCAI) was longer in the delirium group, 4783.0 seconds versus 4204.5 seconds (p = .047), with a cut-off at 4380 s. Longer cardiopulmonary bypass (CPB) leads to prolonged CA impairment (p < .001). The mean arterial pressure (MAP) during CPB was 69.67 mmHg in the non-delirium group and 74.91 mmHg in the delirium group (p = .001), with a cutoff at 73.669 mmHg.

CA impairment is crucial for delirium development after cardiac surgery. The duration of the TCAI event increases the risk of delirium.

The bleeding in cardiac surgery remains a significant clinical problem. There is no “gold standard” method to quantify blood loss. Traditional measurement of drainage volume often underestimates or overestimates, as it does not consider the type of fluid. We hypothesized that blood loss could be more accurately calculated using the Hb/kg index in terms of haemoglobin (Hb) mass loss per kilogram of the patient’s body mass.

To develop a novel approach for calculating actual blood loss using the Hb/kg index.

This single-center prospective study included 195 patients who underwent cardiac surgery between October 2023 and November 2024. The Hb/kg index was calculated based on intraoperative Hb loss, Hb loss via chest tubes, packed red blood cell transfusions and patient weight. Eighty-six additional clinical predictors were analyzed using conventional statistics and machine learning algorithms. Predictors with statistically significant Spearman correlations were included for further analysis.

Lasso regression achieved the best overall performance in predicting Hb/kg index. It yielded the lowest mean squared error (0.08 ± 0.04), mean absolute percentage error (0.18 ± 0.10), with the highest correlation (0.92 ± 0.06) and R² score (0.82 ± 0.13). BMI showed a significant negative relationship (−0.018, p < 0.001). Postoperative Hb and haematocrit values had negative correlation (−0.69, p < 0.001 and −0.07, p < 0.015), while initial Hb was positively correlated (0.85, p < 0.001).

This method provides a more reliable and clinically relevant tool to calculate actual blood loss and allows for a more precise assessment and treatment.

Traditional cardioplegia strategies often fail in cases with patent coronary grafts due to continuous myocardial perfusion, this necessitates for alternate approaches such as systemic hyperkalemic cardiac arrest. During redo cardiac surgeries, a patent left internal mammary artery (LIMA) might prevent the heart from maintaining electrical cardiac arrest. Induced systemic hyperkalaemia is a novel approach to maintain cardiac electromechanical arrest.

We report a case of 66 year-old male with a history of Post CABG for Triple vessel disease (TVD) who required mini-thoractomy for left atrial myxoma excision. Given the existence of patent coronary grafts, attaining cardiac arrest with standard cardioplegia was not possible, necessitating the use of systemic hyperkalaemia for myocardial arrest. The patient was placed on Femoro-femoral cardiopulmonary bypass (CPB) and cooled to 20°C. To induce myocardial arrest, multiple potassium boluses were delivered, totalling 120 mEq/L potassium chloride (KCl) over multiple stages. Despite high potassium levels (6.7 mEq/L in the third arterial blood gas), CPB was successfully weaned off, and the surgical recuperation went smoothly. This case highlights the complexities of myocardial protection in redo cardiac surgery and underscores the role of systemic hyperkalaemia, perfusion management, ultrafiltration, and careful electrolyte management in such high-risk settings. To the best of our knowledge this is the first documented case report of its kind internationally. While there are previous reports of left atrial myxoma excision in post-CABG patients, including those managed using ventricular fibrillation, this is the first reported case in which systemic hyperkalemia combined with deep hypothermia was successfully utilized via a mini-thoracotomy approach in a post-CABG patient with a patent LIMA graft, without the use of aortic cross-clamping or ventricular fibrillation.

This case shows the complexities of myocardial protection in redo cardiac surgeries with patent grafts. The use of systemic hyperkalemia is a viable but challenging alternative to cardioplegia, requiring meticulous potassium management and close hemodynamic monitoring.

Tremelimumab in combination with Durvalumab has recently been approved for the treatment of unresectable hepatocellular carcinoma (HCC). While immune checkpoint inhibitors (ICIs) have transformed cancer therapy, they are associated with rare but potentially fatal immune-related adverse events, including myocarditis.

We report a case of fulminant myocarditis in a 66-year-old female with advanced HCC, 38 days after initiating the Tremelimumab/Durvalumab STRIDE protocol. She presented with cardiogenic shock requiring V-A ECMO support. High-dose corticosteroid therapy resulted in full recovery of cardiac function.

ICI-associated myocarditis has a reported prevalence of 1.14%, with a high rate of major adverse cardiac events. We reported a case of Tremelimumab/Durvalumab-associated myocarditis requiring mechanical circulatory support. Prompt recognition and immunosuppression were critical for recovery.

Clinicians should maintain a high index of suspicion for myocarditis in patients on ICI therapy, as early intervention can be lifesaving.