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Background: Postcardiotomy extracorporeal membrane oxygenation (ECMO) in pediatric patients can be affected by the place of initiation, either in the operating room (OR) or the pediatric cardiac intensive care unit (PCICU). This study aimed to characterize and compare patients who had postcardiotomy ECMO initiation in the OR or PCICU and evaluate risk factors for hospital mortality., Methods: This retrospective study included 103 patients who required postcardiotomy ECMO support after the repair of congenital cardiac lesions from 2010 to 2022. Patients were grouped according to the place of ECMO insertion into two groups. Group 1 ( n = 69) had ECMO insertion in the OR, and Group 2 ( n = 34) had ECMO insertion in the PCICU., Results: Cardiac arrest occurred significantly more often in patients with ECMO insertion in the PCICU (21 (61.76%) vs. 13 (18.84%); p < 0.001). Pre-ECMO lactate levels, pH, VIS, base deficit, and PaO 2 did not differ between the groups. Re-exploration for bleeding was significantly higher in Group 1 (32 (46.38%) vs. 8 (23.53%); p = 0.03). Cannula repositioning (4 (11.76%) v. 2 (2.90%); p = 0.09) and mechanical ventilation time were nonsignificantly higher in Group 2 (19.5 (10-31) vs. 11 (5-25) days; p = 0.07). No difference in mortality was found between groups (42 (60.87%) vs. 23 (67.65%), p = 0.50). By multivariable analysis, elevated lactate on ECMO and low pH before ECMO were associated with mortality., Conclusions: ECMO insertion in the OR has a comparable mortality rate to PCICU insertion. Pre-ECMO low pH and high lactate during ECMO could predict mortality., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is associated with significant mortality. Identification of patients at very high risk for death is elusive and the decision to initiate V-A-ECMO is based on clinical judgment. The prognostic impact of pre-V-A-ECMO arterial lactate level in these critically ill patients has been herein evaluated., Methods: A systematic review was conducted to identify studies on postcardiotomy VA-ECMO for the present individual patient data meta-analysis., Results: Overall, 1269 patients selected from 10 studies were included in this analysis. Arterial lactate level at V-A-ECMO initiation was increased in patients who died during the index hospitalization compared to those who survived (9.3 vs 6.6 mmol/L, p < 0.0001). Accordingly, in hospital mortality increased along quintiles of pre-V-A-ECMO arterial lactate level (quintiles: 1, 54.9%; 2, 54.9%; 3, 67.3%; 4, 74.2%; 5, 82.2%, p < 0.0001). The best cut-off for arterial lactate was 6.8 mmol/L (in-hospital mortality, 76.7% vs. 55.7%, p < 0.0001). Multivariable multilevel mixed-effect logistic regression model including arterial lactate level significantly increased the area under the receiver operating characteristics curve (0.731, 95% CI 0.702-0.760 vs 0.679, 95% CI 0.648-0.711, DeLong test p < 0.0001). Classification and regression tree analysis showed the in-hospital mortality was 85.2% in patients aged more than 70 years with pre-V-A-ECMO arterial lactate level ≥6.8 mmol/L., Conclusions: Among patients requiring postcardiotomy V-A-ECMO, hyperlactatemia was associated with a marked increase of in-hospital mortality. Arterial lactate may be useful in guiding the decision-making process and the timing of initiation of postcardiotomy V-A-ECMO., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Limited data evaluated the outcomes of extracorporeal membrane oxygenation (ECMO) in patients with prosthetic valves. This study aimed to compare the outcomes of ECMO support for postcardiotomy cardiogenic shock in patients with mechanical versus bioprosthetic valves., Methods: This retrospective study included patients with ECMO support for postcardiotomy cardiogenic shock after valve replacement. Patients were grouped into bioprosthetic ( n = 49) and mechanical valve ( n = 22) groups., Results: There were no differences in ECMO duration, inotropic support, intra-aortic balloon pump (IABP), stroke, duration of ICU, and hospital stay between groups. Postoperative thrombosis occurred in 2 patients with bioprosthetic valves (5.41%) and 2 with mechanical valves (14.29%), p = .30. All patients with thrombosis had central ECMO cannulation, concomitant IABP, and inotropic support during ECMO. All thrombi were related to the mitral valve. Three patients with thrombi had hospital mortality.Survival at 6, 12, and 36 months for bioprosthetic valve patients was 30.88%, 28.55%, and 25.34% and for mechanical valves was 36.36% for all time intervals (Log-rank p = .93). One patient had bioprosthetic aortic valve endocarditis after 1 year. Three patients with bioprosthetic valves had structural valve degeneration after 1, 2, and 5 years., Conclusions: Outcomes of ECMO in patients with prosthetic valves are comparable between bioprosthetic and mechanical valves. Thrombosis might occur in both valve types and was associated with high mortality. ECMO could affect the long-term durability of the bioprosthetic valves., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Reliable stratification of the risk of early mortality after postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) remains elusive. In this study, we externally validated the PC-ECMO score, a specific risk scoring method for prediction of in-hospital mortality after postcardiotomy V-A-ECMO. Overall, 614 patients who required V-A-ECMO after adult cardiac surgery were gathered from an individual patient data meta-analysis of nine studies on this topic. The AUC of the logistic PC-ECMO score in predicting in-hospital mortality was 0.678 (95%CI 0.630-0.726; p  < 0.0001). The AUC of the logistic PC-ECMO score in predicting on V-A-ECMO mortality was 0.652 (95%CI 0.609-0.695; p  < 0.0001). The Brier score of the logistic PC-ECMO score for in-hospital mortality was 0.193, the slope 0.909, the calibration-in-the-large 0.074 and the expected/observed mortality ratio 0.979. 95%CIs of the calibration belt of fit relationship between observed and predicted in-hospital mortality were never above or below the bisector ( p  = 0.072). The present findings suggest that the PC-ECMO score may be a valuable tool in clinical research for stratification of the risk of patients requiring postcardiotomy V-A-ECMO., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Patients requiring postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) have a high risk of early mortality. In this analysis, we evaluated whether any interinstitutional difference exists in the results of postcardiotomy V-A-ECMO., Methods: Studies on postcardiotomy V-A-ECMO were identified through a systematic review for individual patient data (IPD) meta-analysis. Analysis of interinstitutional results was performed using direct standardization, estimation of observed/expected in-hospital mortality ratio and propensity score matching., Results: Systematic review of the literature yielded 31 studies. Data from 10 studies on 1269 patients treated at 25 hospitals were available for the present analysis. In-hospital mortality was 66.7%. The relative risk of in-hospital mortality was significantly higher in six hospitals. Observed versus expected in-hospital mortality ratio showed that four hospitals were outliers with significantly increased mortality rates, and one hospital had significantly lower in-hospital mortality rate. Participating hospitals were classified as underperforming and overperforming hospitals if their observed/expected in-hospital mortality was higher or lower than 1.0, respectively. Among 395 propensity score matched pairs, the overperforming hospitals had significantly lower in-hospital mortality (60.3% vs 71.4%, p  = 0.001) than underperforming hospitals. Low annual volume of postcardiotomy V-A-ECMO tended to be predictive of poor outcome only when adjusted for patients' risk profile., Conclusions: In-hospital mortality after postcardiotomy V-A-ECMO differed significantly between participating hospitals. These findings suggest that in many centers there is room for improvement of the results of postcardiotomy V-A-ECMO., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The optimal venoarterial extracorporeal membrane oxygenation (VA ECMO) cannulation strategy in patients with postcardiotomy cardiogenic shock is still debatable. Studies evaluating the effect of cannulation strategy on long-term survival are scarce., Objectives: We investigated the impact of central versus peripheral cannulation strategy for ECMO insertion on hospital outcomes and survival in postcardiotomy cardiogenic shock patients., Methods: This retrospective study involved 101 patients who had either central or peripheral ECMO due to postcardiotomy shock between June 2009 and December 2020. Study endpoints were limb ischemia, bleeding, blood transfusion, wound infection, and overall survival., Results: Eighty-four patients received central (c) ECMO, and 17 patients had peripheral (p) ECMO. In the group of pECMO, limb ischemia was significantly higher (5 [29.41%] vs 6 [7.14%]; p = .01). Other endpoints were similar in both groups. Thirty-day mortality was nonsignificantly different between both cohorts (cECMO 34 [41.67%] vs pECMO 10 [58.82%]; p = .29). However, overall survival was better with cECMO (Log-rank p = .02). Patients' age [HR: 1.04 (95% CI: 1.02-1.06); p = .001], pECMO [HR: 1.98 (95% CI: 1.11-3.55), p = .002] and presence of infective endocarditis [HR: 3.54 (95% CI: 1.52-8.24), p = .03] were significant predictors of overall mortality., Conclusions: Peripheral ECMO was associated with an increased risk of limb ischemia; however, bleeding, blood transfusion, infection, and 30-day mortality were comparable to central ECMO. Central cannulation was associated with a better 1-year survival rate. Therefore, central cannulation might be the preferred strategy for patients with postcardiotomy cardiogenic shock., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

We aimed to compare the outcomes of ECMO with and without IABP for postcardiotomy cardiogenic shock. The study included 103 patients who needed ECMO for postcardiotomy cardiogenic shock. Patients were grouped according to the use of IABP into ECMO without IABP ( n  = 43) and ECMO with IABP ( n  = 60). The study endpoints were hospital complications, successful weaning, and survival. Patients with IABP had lower preoperative ejection fraction ( p  = 0.002). There was no difference in stroke ( p  = 0.97), limb ischemic ( p  = 0.32), and duration of ICU stay ( p  = 0.11) between groups. Successful weaning was non-significantly higher with IABP (36 (60%) vs 19 (44.19%); p  = 0.11). Predictors of successful weaning were inversely related to the high pre-ECMO lactate levels (OR: 0.89; p  = 0.01), active endocarditis (OR: 0.06; p  = 0.02), older age (OR: 0.95; p  = 0.02), and aortic valve replacement (OR: 0.26; p  = 0.04). There was no difference in survival between groups ( p  = 0.80). Our study did not support the routine use of IABP during ECMO support.

Background: Sepsis could affect the outcomes of patients with postcardiotomy cardiogenic shock supported with extracorporeal membrane oxygenation (ECMO). Our objectives were to characterize sepsis patients with ECMO support for postcardiotomy cardiogenic shock and assess its predictors and effect on patients' outcomes., Methods: This retrospective study included 103 patients with ECMO for postcardiotomy cardiogenic shock from 2009 to 2020. Patients were divided according to the occurrence and timing of sepsis into three groups. Group 1 included patients with no sepsis ( n  = 67), Group 2 included patients with ECMO-related sepsis ( n  = 10), and Group 3 included patients with non-ECMO-related sepsis ( n  = 26)., Results: Lactate level before ECMO was highest in the ECMO-associated sepsis group (Group 1 and 2 p  = 0.003 and Group 2 and 3 p  = 0.003). Dialysis and gastrointestinal bleeding were highest in ECMO-associated sepsis ( p  = 0.03 and 0.04, respectively). Blood transfusion was higher in ECMO-associated sepsis than in patients with no sepsis ( p  = 0.01). Mortality was nonsignificantly higher in patients with ECMO-associated sepsis. High BMI (OR: 1.11; p  = 0.004), preoperative dialysis (OR: 7.35; p  = 0.02), preoperative IABP (OR: 9.9.61; p  = 0.01) and CABG (OR: 6.29; p  = 0.01) were significantly associated with sepsis. Older age (OR: 1.08; p = 0.004), lower BSA (OR: 0.004; p  = 0.003), peripheral cannulation (OR: 29.82; p  = 0.03), and high pre ECMO lactate level (OR: 1.24; p  = 0.001) were associated with increased mortality. Sepsis did not predict mortality (OR: 1.83; p  = 0.21)., Conclusions: Sepsis is a dreaded complication in patients with postcardiotomy cardiogenic shock, especially ECMO-associated sepsis. Preoperative risk factors could predict postoperative sepsis in ECMO patients.