Heart failure (HF) readmissions remain common and adversely affect morbidity and quality of life in durable left ventricular assist device (LVAD) recipients. This study sought to describe the clinical impact of HF readmissions following HeartMate 3 (HM3) LVAD implantation. We conducted a single-center analysis of patients undergoing HM3 implantation between January 2015 and December 2021. Cumulative incidence functions were used to estimate HF readmission, and multistate models evaluated transitions from LVAD implantation to recurrent HF readmissions and death. Among 273 patients with HM3 implantation, the mean age was 58 years, 75% were men, and 78% were Black. Overall, 78 patients (29%) experienced at least one HF readmission. Preimplant diabetes mellitus and higher body mass index were significant predictors of HF readmission. Heart failure readmissions occurred more frequently than death throughout follow-up (1 year: 20.8% vs. 8.5%; 4 years: 30.5% vs. 23.4%). Readmissions were highly recurrent, and mortality risk increased with each additional HF readmission (4 year adjusted mortality: 31.2% and 39.3% after the first and second HF readmission, respectively). Heart failure readmissions remain a major source of morbidity among HM3 LVAD recipients. Recurrent readmissions are associated with a stepwise increase in mortality and these findings underscore the need for targeted strategies to prevent recurrent HF readmissions in this population.

An obese female patient with ischemic cardiomyopathy was placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock after in-hospital cardiac arrest. Despite biventricular recovery by day 3, VA-ECMO weaning was deferred due to persistent severe hypoxemia. To investigate cardiopulmonary pathophysiology, electrical impedance tomography (EIT) assessment was performed. Electrical impedance tomography-guided positive end-expiratory pressure (PEEP) titration confirmed that set PEEP minimized lung collapse, reducing the likelihood that intrapulmonary shunt was the primary cause of hypoxemia. With ventilator settings unchanged, EIT-based lung perfusion was assessed at VA-ECMO blood flows of 4.2 and 2.0 L/min. At lower (2.0 L/min) VA-ECMO blood flow, ventilation/perfusion (V/Q) matching significantly improved, primarily due to increased transpulmonary blood flow, which was redistributed from dorsal to ventral regions. Thus, by bypassing pulmonary circulation, higher VA-ECMO blood flow worsened V/Q mismatch and significantly contributed to hypoxemia. With these insights and after a successful weaning trial the next day, VA-ECMO was removed, and extubation followed 10 days later. To our knowledge, this is the first report of EIT enabling bedside assessment of the impact of VA-ECMO on regional lung perfusion, revealing an underrecognized iatrogenic contributor to hypoxemia. These findings underscore the distinctive value of EIT in tailoring cardiorespiratory care for VA-ECMO patients.

The optimal timing of percutaneous coronary intervention (PCI) in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) who are supported with venoarterial extracorporeal membrane oxygenation (VA-ECMO) remains uncertain. We aimed to evaluate the prognostic impact of shock-to-balloon time (STB) in AMI-CS patients supported with VA-ECMO before revascularization. This study included patient-pooled data from CS-dedicated registries, including the SMART-RESCUE and the SMC-ECMO. A total of 256 patients were included. Patients were stratified according to STB (<120 min, n = 140; ≥120 min, n = 116). Among the study population, all-cause mortality was significantly higher in the ≥120 minutes group compared with the <120 minutes group (65.2% vs. 44.6%; adjusted hazard ratio [HR]: 1.59, 95% confidence interval [CI]: 1.03-2.45, p = 0.037). This association was significant in the ST-segment elevation myocardial infarction (STEMI) subgroup (adjusted HR: 2.22, 95% CI: 1.26-3.93), and in patients with earlier (<60 min) VA-ECMO initiation (adjusted HR: 2.50, 95% CI: 1.42-4.38), whereas in the non-ST-segment elevation myocardial infarction (NSTEMI) subgroup a directionally consistent but nonsignificant trend was observed, without significant interaction (p-for-interaction = 0.164). In AMI-CS patients who underwent VA-ECMO, a prolonged STB was associated with higher all-cause mortality, with a consistent but exploratory trend in NSTEMI. These findings support STB as a prognostic marker and warrant prospective evaluation of coordinated ECMO-revascularization pathways.

In this retrospective cohort study at a quaternary referral hospital, 829 adult patients supported by extracorporeal membrane oxygenation (ECMO) between January 1, 2014, and October 31, 2024, were screened for ventilator-associated pneumonia (VAP). The incidence of VAP in ECMO-supported patients was 17.7 per 1,000 ECMO days (venoarterial [VA] ECMO, 22.1 per 1,000 ECMO days; venovenous [VV] ECMO, 13.8 per 1,000 ECMO days). Median time from ECMO cannulation to diagnosis of VAP was 4 (interquartile range [IQR], 3-8; range 1-84) days. Gram-negative bacteria comprised most respiratory pathogens. A significant increase in minimum ECMO sweep was noted from 2 days before to 1 day after VAP diagnosis (0.79 L/min increase, p = 0.004). Only 38 of 153 patients (24.8%) met National Healthcare Safety Network (NHSN) VAP definitions. After creating a modified VAP definition, which included an ECMO sweep increase of 0.5 L/min as evidence of worsening respiratory status, 78 (51.0%) met the modified definition. Those who met the modified VAP definition had worse in-hospital (60.3% vs. 28.0%, p < 0.001), 30 day (33.3% vs. 17.3%, p = 0.023), and 90 day (53.8% vs. 25.3%, p < 0.001) mortality compared with those who did not meet the modified VAP definition. The incorporation of ECMO parameters into diagnostic criteria may improve detection sensitivity, but further validation is necessary before implementation.

Oxygenator thrombosis is a major complication during extracorporeal membrane oxygenation (ECMO), but systemic anticoagulation may be contraindicated by active hemorrhage, recent surgery, intracranial injury, or severe coagulopathy. Circuit-directed nitric oxide (NO) delivered into the oxygenator sweep gas may provide localized antiplatelet activity at the blood-circuit interface without intentionally producing systemic anticoagulation. We conducted a single-center retrospective case series of adult extracorporeal membrane oxygenation (ECMO) patients treated between January 1, 2025, and May 31, 2026, who received circuit-directed NO while systemic anticoagulation and antiplatelet therapy were withheld due to clinically significant bleeding risk. Nitric oxide was delivered at 20 ppm via a NOxBOXi system connected to the oxygenator sweep-gas pathway. Ten patients received circuit-directed NO: three venovenous, six venoarterial, and one venopulmonary arterial, for durations of 2-72 days. No patient required oxygenator exchange for thrombosis, gas-exchange failure, progressive trans-oxygenator pressure-gradient elevation, or hemolysis. The trans-oxygenator pressure gradient remained below 50 mm Hg in all patients. Maximum methemoglobin ranged from 1.0% to 3.4%, and no patient required NO discontinuation. Nine of 10 patients survived to decannulation. In this small uncontrolled series, circuit-directed NO was feasible and not associated with NO-attributable safety events or oxygenator exchange; efficacy cannot be inferred.

Venovenous extracorporeal membrane oxygenation (VV ECMO) may be a life-saving intervention for patients with severe respiratory failure. While short-term benefits are evident, there is still little data on ECMO in appropriately selected patients, and evidence on functional outcomes is limited. All patients from the Freiburg Extracorporeal Membrane Oxygenation Outcome Study (FEOS) with COVID-19 supported with VV ECMO between March 2020 and March 2022 at the Freiburg University were included. During the study period, 97 patients were supported with VV ECMO, and hospital survival was 44.3%. Survivors were invited to participate in a follow-up examination. Complete follow-up examination was available in 15 of 97 (15.5%) after 1.86 ± 0.41 years. In the 6 Minute Walk Test, patients walked 474 (216-591) m (81% of predicted), and desaturation occurred in 53.3%. Cardiopulmonary Exercise Testing showed peak peak oxygen uptake (VO2) of 17.8 ml/min/kg (10.8-23.3), with moderate exercise limitation in 13.3%. Tricuspid annular plane systolic excursion was preserved (24.4 ± 4.4 mm), and right ventricle (RV) and right atrium (RA) dilatation was mild to moderate in 46.7%. Body plethysmography showed a total lung capacity of 76.3% (51-99%) and reduced diffusing capacity for carbon monoxide of 66.2% (40-93%). These findings suggest that a substantial portion of VV ECMO survivors exhibit functional limitations after discharge and support the need for structured pulmonology and cardiology follow-up after VV ECMO.

Extracorporeal membrane oxygenation (ECMO) is a vital therapy for patients with severe cardiac and pulmonary failure. Despite technological advances, oxygenator dysfunction remains common, yet comparative clinical data across devices are limited. This study evaluated the performance of four contemporary adult oxygenators used in ECMO in a clinical, real-world setting. This retrospective single-center study included adult patients who received venovenous (VV) or venoarterial (VA) ECMO between January 2020 and December 2023 (N = 282). Oxygenators evaluated included the Medtronic Nautilus/Nautilus Smart, Getinge Heart Lung Support Module Advanced 7.0, Getinge Quadrox-iD Adult, and Fresenius X-Lung. Analyses were performed using propensity weighting and included adjustments for Acute Physiology and Chronic Health Evaluation II severity scores and baseline Charlson Comorbidity Index (CCI). No statistically significant differences in oxygen transfer across the membrane lung (VO2) were observed among oxygenator types after adjustment for covariates. VO2 declined over time during support (p < 0.001) and was higher in VV than VA ECMO mode (p = 0.002). Higher CCI was associated with lower VO2 (p = 0.046). Finally, coagulation and hemolysis markers were comparable across all devices. Current-generation oxygenators provide similar gas exchange efficiency and hemocompatibility in clinical practice. Future prospective and multicenter studies incorporating direct measurements of gas transfer may further clarify device-specific characteristics and their impact on clinical outcomes.

Intra-aortic balloon pumps (IABPs), designed for femoral access, are increasingly used in the axillary position to support patients awaiting advanced heart failure (HF) therapies. These devices often migrate, requiring radiographic surveillance-based repositioning. We evaluated how often axillary IABPs (ax-IABPs) require repositioning and whether repositioning worsens outcomes. We conducted a single-center retrospective cohort study of patients with advanced HF and cardiogenic shock supported by ax-IABPs. The primary outcome was a composite of ax-IABP-related complications: device malfunction requiring exchange, bacteremia, vascular complications, pneumothorax, and stroke. Thirty-eight patients received 55 ax-IABPs. Mean age was 50.7 years, 71% male; non-ischemic cardiomyopathy predominated (51%). Repositioning was required in 49% of devices (mean 2.2 events each). Complications occurred more frequently in repositioned devices (22 vs. 14 events), most commonly pump malfunction requiring exchange, followed by axillary artery thrombosis/upper-extremity ischemia and bacteremia. Repositioning was associated with higher odds of complications in unadjusted (OR: 5.9; 95% confidence interval [CI]: 1.7-20.0; p = 0.005) but not adjusted analysis (OR: 3.5; 95% CI: 0.7-17.4; p = 0.13). Competing-risks analysis showed a time-dependent increase in complication risk during prolonged support. Nearly half of ax-IABPs require repositioning, which is associated with worse outcomes. Findings call for vigilance and improved ax-IABP design and durability.

Mechanical circulatory support (MCS) restores flow using blood pumps with ventriculoarterial (VA) uncoupling and unloading. Blood contact contributes to bleeding, thromboembolism, and infection. Direct mechanical ventricular actuation (DMVA) maintains VA coupling and augments ventricular expansion and end-diastolic geometry. These effects differ from conventional MCS. This study evaluated postsupport cardiac function following DMVA compared with a clinically available left ventricular assist device (LVAD) in a chronic heart failure (HF) model. Chronic HF was induced in adult canines using rapid ventricular pacing or serial coronary microembolization. Animals were assigned to 2 hours of DMVA or LVAD. Hemodynamic measurements, pressure-volume analyses, and dobutamine stress responses were assessed postsupport. Support was successfully maintained in all animals. After device removal, DMVA was associated with significant improvements in preload-recruitable stroke work and end-diastolic pressure-volume relationships. Dobutamine responsiveness was preserved after DMVA but blunted following LVAD. No postsupport improvements in systolic or diastolic function were observed after LVAD support. Direct mechanical ventricular actuation resulted in salutary effects on systolic and diastolic function in chronically failing hearts, whereas LVAD support did not. Unlike LVAD support, DMVA maintains VA coupling and exerts salutary effects on the failing heart, notably improving diastolic function. Synchronous DMVA support may further enhance these effects.

To optimize and evaluate the hydrodynamic performance and gas exchange efficiency of a newly developed centrifugal blood pump and membrane oxygenator for extracorporeal membrane oxygenation (ECMO) support, blood pump and oxygenator designs were optimized from a hydrodynamic perspective by adopting a five-blade impeller for the pump and a circular flow path with a central inlet and bottom outlet for the oxygenator. Computational fluid dynamics (CFD) was used to evaluate shear distribution. In vitro experiments assessed pressure-flow characteristics. Long-term ECMO support (14 days) was performed in sheep using both venovenous (VV) and venoarterial (VA) modes. Key parameters, including plasma-free hemoglobin and comprehensive blood tests (biochemistry, coagulation, platelet function), were analyzed. Computational fluid dynamics revealed uniform pump flow with minimal high-shear volume and negligible stagnation in the oxygenator, indicating low hemolysis and thrombosis risk. In vitro, the oxygenator showed lower transmembrane pressure than Quadrox-PLS across 1-7 L/min and higher O2 transfer (1-3 L/min). In vivo, circuit flow was stable (2.2 L/min [VV], 2.5 L/min [VA]) and oxygenator ΔP remained 10-12 mm Hg with stable oxygen exchange (155 ml/min [VV], 165 ml/min [VA]), and plasma-free hemoglobin (pfHb) remained below 50 mg/dL. Three non-device-related deaths occurred, and there were no device-related thrombotic or hemorrhagic complications. The ECMO system demonstrated excellent mechanical stability, effective long-term oxygenation, favorable hemodynamic performance, and outstanding hemocompatibility in large-animal models.

Unbalanced pressures and volumes between the right and left atrium will cause systemic and/or pulmonary congestion. The continuous-flow (CF) total artificial hearts (TAHs) developed at the Cleveland Clinic mitigate pressure imbalance by titrating right pump output via pressure-related changes in rotor axial position. Hall effect sensors were placed and calibrated at both ends of the pediatric CF TAH (P-CFTAH) stator bore to track the rotor's permanent magnet location. The P-CFTAH was placed on a mock loop in water/glycerin, where several hemodynamic conditions, both pulsatile flow (PF) and CF, were tested while recording both left and right atrial pressures (LAP and RAP), outlet pressures (aortic pressure [AoP] and pulmonary artery pressure [PAP]), flows, and Hall effect sensor output. There was a positive correlation of ≥0.80 (p < 0.0001) between rotor position and flow, and a negative correlation of ≥-0.80 (p < 0.0001) between rotor position and atrial balance, systemic vascular resistance (SVR), and LAP. The rotor's maximum movement per cycle during pulsatile testing was 1.32 mm, and the minimum was 0.51 mm, indicating a significant positive correlation (≥0.80; p < 0.0001) with pulse pressure and flow pulse. The passive balancing features of P-CFTAH are effective across a range of steady-state conditions.

Although some patients may exhibit significant myocardial improvement after the placement of a durable left ventricular assist device (LVAD), there are no established guidelines on determining patients who may be eligible for explantation. In this single-center case series, three patients were evaluated for LVAD explantation 8-24 months after implantation using a rigorous multimodality protocol along with multidisciplinary team discussions to assess appropriateness for explantation. Although two of the patients have remained successful device-free, the third patient ultimately underwent heart transplantation 2 months post-explantation. We propose evaluating this protocol more broadly in patients with durable LVADs who demonstrate improved left ventricular function with the goal of ultimately developing standardized guidelines to assess appropriateness for LVAD explantation.

The HeartMate 3 (HM3) left ventricular assist device (LVAD), initially designed for adults, is increasingly utilized in children, small adults, and those with congenital heart disease (CHD), necessitating expanded knowledge and collaborative efforts. This review highlights key physiologic and management considerations for these unique populations. The HM3's magnetic levitation and artificial pulse mitigate thrombotic risk, but understanding the interplay of pump power, flow, and pulsatility index is crucial, particularly in smaller patients due to their unique power-flow dynamics and pressure sensitivities. Preoperative assessment must carefully consider patient size, left ventricle dimensions, and anatomical suitability. Postoperative management requires individualized anticoagulation, secure driveline placement, and optimized pain control, with specific considerations for varying CHD physiologies, such as Fontan circulation. A multidisciplinary approach is paramount in patients with muscular dystrophy, addressing infection risk, respiratory compromise, and quality of life. Successful HM3 implementation requires comprehensive patient/family education, rehabilitation, psychosocial support, and careful device optimization. Continued collaborative real-world data sharing, particularly regarding long-term outcomes, is essential to refine best practices and optimize support for these complex patients.

Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for critically ill children. However, decisions regarding discontinuation due to poor prognosis remain ethically complex. While outcomes after successful weaning are well described, survival following decannulation for perceived futility is poorly understood. We conducted a retrospective cohort study using the Extracorporeal Life Support Organization (ELSO) registry, including pediatric ECMO runs from 2013 to 2023. Among 6,662 cases decannulated for poor prognosis, we identified patients who survived until hospital discharge. Patient characteristics, ECMO parameters, complications, and outcomes were compared between survivors and nonsurvivors. Of 6,662 cases, 18 patients (0.3%) survived to discharge. Baseline characteristics were similar between groups. Survivors more often had pulmonary indications (44% vs. 27%, p = 0.2) and significantly lower pre-ECMO lactate levels (median 2.7 vs. 6.2 mmol/L, p = 0.031). They also experienced fewer on-ECMO complications (median 1 vs. 2, p = 0.11) and longer ECMO duration (8 vs. 4 days, p = 0.07). Venoarterial support was less frequent among survivors (61% vs. 80%). Survival after ECMO decannulation for poor prognosis is rare but possible (1/370 cases). Lower pre-ECMO lactate levels and pulmonary indications may indicate potential for unexpected recovery, highlighting uncertainty in prognostication and the importance of individualized, multidisciplinary decision-making.

Left ventricular (LV) distension is a life-threatening complication of venoarterial extracorporeal membrane oxygenation (VA-ECMO), requiring prompt venting in the setting of uncertain neurological prognosis. Current strategies, microaxial devices and surgical venting, are costly or invasive. A 55 year old male with cardiac arrest on VA-ECMO developed severe LV distension with refractory ventricular fibrillation. A 17 French Bio-Medicus cannula was inserted percutaneously via the right axillary artery and connected to the ECMO venous limb, achieving effective LV unloading in 8 minutes. Hemodynamic stability was maintained for 48 hours, enabling neurological assessment and successful organ donation. Percutaneous axillary venting is a cost-effective, rapidly deployable option for LV decompression during VA-ECMO, preserving therapeutic flexibility for cardiac recovery or organ donation.