BackgroundThe effect of the anticoagulant, dabigatran, and its antagonist, idarucizumab, on coagulation remains poorly quantified. There are few pharmacokinetic-pharmacodynamic data available to describe the interaction in humans or animals undergoing cardiopulmonary bypass.MethodsSix sheep were given intravenous dabigatran infusion while undergoing cardiopulmonary bypass. Blood samples were collected for thromboelastographic reaction time (R-time) and drug assay at 1. 5, 15, 30, 60, 90, and 120 min after starting dabigatran. Further reaction times were measured at 1 min, 5 min, 15 min, 60 min, 4 h and 24 h after initiation of idarucizumab infusion. Plasma dabigatran concentrations, the dabigatran- idarucizumab interaction and R-times were analyzed using an integrated pharmacokinetic-pharmacodynamic model with non-linear mixed effects.ResultsA 2-compartment model described dabigatran pharmacokinetics with a clearance (CL 0.0509 L/min/70 kg), intercompartment clearance (Q 0.229 L/min/70 kg), central volume of distribution (V1 3.89 L/70 kg), peripheral volume of distribution (V2 11.4 L/70 kg). The peripheral volume was 2.25 times larger during bypass. The effect compartment model estimates for an E model using reaction time had an effect site concentration (Ce 40.8 mg/L) eliciting half of the maximal effect (E 180 min). A potency factor for the antagonist, idarucizumab (EA 29.9 mg/L), moved the dabigatran response relationship to the left.ConclusionsDabigatran reversibly binds to the active site on the thrombin molecule, preventing activation of coagulation factors. Expansion of peripheral volume of distribution of dabigatran was observed during cardiopulmonary bypass, contributing to observed concentrations lower than predicted. A competitive interaction model adequately described dabigatran reversal by idarucizumab. These data and consequent parameter estimates inform future clinical studies in both animals and humans.

BackgroundMediastinal masses in children secondary to malignancy can cause significant airway and great vessel compression, leading to respiratory and cardiovascular compromise. Extracorporeal membrane oxygenation (ECMO) has been described as a bridge to diagnosis and treatment for masses causing cardiopulmonary instability.ObjectivesTo evaluate outcomes of pediatric oncologic patients requiring ECMO for mediastinal masses.MethodsWe conducted a sub-analysis of a previously published multicenter cohort study examining ECMO outcomes in pediatric hematologic and oncologic patients from 2009 to 2021. Patients less than 19 whose disease presented as a mediastinal mass were included. Presenting features, ECMO characteristics, and outcomes were analyzed.ResultsEleven patients with mediastinal masses were identified, 7 with solid tumors and 4 with hematologic malignancies. The indications for ECMO were combined cardiac and respiratory failure in 64%, respiratory failure in 27%, and cardiac failure in 9%. ECMO survival was 72% (8/11), and survival to hospital discharge was 45% (5/11). Upon separation into solid tumor and hematologic malignancy groups, the ECMO survival was 71% (5/7) and 75% (3/4), and survival to hospital discharge was 29% (2/7) and 75% (3/4), respectively. Patients with solid tumors had longer intensive care unit (ICU) lengths of stay (LOS) and hospital LOS.ConclusionsOur study supports ECMO cannulation for patients with mediastinal masses secondary to hematologic malignancies that require advanced cardiopulmonary support. However, due to poorer outcomes in solid tumors, ECMO candidacy should be carefully considered in this population.

IntroductionAtrial fibrillation (AF) is the most common arrhythmia worldwide, yet long-term outcomes in conflict-affected regions are poorly understood. Gender-based disparities in AF outcomes have been reported in high-income countries but remain unexplored in fragile healthcare systems.MethodsWe conducted a retrospective cohort study at Latakia's University Hospital in Latakia, Syria between June/2021-November/2023. Adult patients admitted with primary AF were followed for 1 year to assess unplanned readmissions. Data on unplanned readmissions were defined as non-elective hospitalisations occurring within 1 year after index discharge. These were unscheduled admissions, usually prompted by recurrence of symptoms, acute decompensation, or cardiovascular events. Data were collected from medical records.ResultsOf the included 657 patients (52% male, median age 60 years), 422 (64%) had at least one unplanned readmission within 1 year. Cardiac causes accounted for 67% of readmissions, with recurrent AF responsible for 75% of those. Females had higher all-cause (73% vs 56%) and cardiovascular (53% vs 34%) readmission rates than males (both < 0.001). On multivariable analysis, independent predictors of readmission included female sex (HR 1.7, 95% CI 1.4-2.0), age ≥60 (HR 3.7, 95% CI 2.9-4.6), diabetes mellites (DM) (HR 1.5, 95% CI 1.2-1.8), and congestive heart failure (CCF) (HR 3.3, 95% CI 2.6-4.6). Females were more likely to have two (44%) or three or more (44%) readmissions than males.ConclusionsOne-year readmissions after AF admission were high, particularly among females. Female gender was an independent risk factor, highlighting the need for gender-sensitive follow-up strategies in resource-limited settings.

BackgroundThe impact of the duration of invasive mechanical ventilation (IMV) before venovenous extracorporeal membrane oxygenation (VV ECMO) on patient outcomes in COVID-19 remains unclear.Methods and settingData from the COVID-19 Critical were used to investigate whether the duration of IMV prior to VV ECMO initiation was associated with ICU mortality between January 1st 2020 and December 31st, 2022. Multivariable Cox regression models were used to evaluate the role of the duration of IMV before ECMO on patient outcomes after adjusting for calendar date and key patient covariates.Results919 adult patients with median age 50 and severe COVID-19 infection requiring IMV and VV ECMO were included in the analysis. The ICU mortality for ECMO performed on the same day as IMV was 43%, compared to 47% when ECMO was initiated between 1 and 7 days and 54% when ECMO was initiated at 8+ days. The 8+ day group of IMV received more prone positioning (71%), neuromuscular blockade (80%), and vasopressor support (74%). The multivariable analysis showed the mortality risk increased when ECMO was initiated within the first 7 days from commencement of IMV (Hazard ratio, HR: 1.37; 95% CI: 1.08 to 1.73) or later (HR: 1.51; 1.02 to 2.22), compared with same-day initiation.ConclusionAnalysis indicated a positive association between time on IMV before VV ECMO initiation and ICU mortality, but effects sizes exhibited high uncertainty after adjusting for other patient characteristics. Further studies are needed to confirm our findings.

IntroductionMycotic thoracic aneurysms in children are rare and carry high mortality, particularly when complicated by erosion into adjacent pulmonary structures. Early recognition and surgical intervention are essential to prevent catastrophic outcomes.Case ReportA 14-year-old presented with respiratory symptoms. Imaging revealed a large mycotic aneurysm of the aorta with compression of multiple mediastinal structures. During induction of anaesthesia, aneurysm rupture caused haemoptysis and hypovolemic arrest. Emergent femoral cannulation enabled initiation of cardiopulmonary bypass and novel use of endotracheal suction with autologous cell salvage facilitated surgical exposure and successful aneurysm repair.DiscussionThoracic mycotic aneurysms present diagnostic complexity and potential catastrophic outcomes. In this patient, rapid multidisciplinary coordination, dual-arterial cannulation and intraoperative blood-salvage techniques proved critical to restoring circulation and achieving surgical control.ConclusionThoracic mycotic aneurysms in children require extreme vigilance and adaptable surgical strategies. This case demonstrates that survival is possible with innovative management in the face of life-threatening complications.

IntroductionMobility and rehabilitation for patients supported on extracorporeal life support (ECLS) are high-risk and resource-intensive endeavors that currently lack a standardized framework to guide comprehensive program development. This paper introduces the framework to serve as a structured model that integrates best practice recommendations, relevant literature, and practical data from an ELSO Gold Level Center of Excellence program.MethodsInitially developed in response to the COVID-19 pandemic, the ECMO mobility program matured into a proactive and sustainable system through multidisciplinary collaboration, incorporation of current evidence, and iterative reflective practice. The resulting framework offers a structured, holistic approach to establishing effective ECLS mobility program.ResultsThe Mobility Under the Support of ECLS ("MUSECLS") framework comprised five interconnected domains, beginning with patient and family engagement and extending to institutional values and infrastructure. Implementation strategies and programmatic data from the originating ECMO center are used to illustrate practical application of the framework.ConclusionsThe MUSECLS framework provides a scalable and adaptable model to support the development or refinement of ECMO mobility and rehabilitation programs. It allows centers to tailor practices to local resources and populations while ensuring a comprehensive, evidence-informed approach. The framework is designed to remain applicable as clinical care and research in ECLS continue to advance.

Lower extremity ischemia in acute type A aortic dissection is associated with severe complications, including amputation, acute kidney injury, and increased mortality. Timely restoration of blood flow is critical to balance the risks of delayed extremity reperfusion against those of postponed central aortic repair. We present a multidisciplinary approach involving early extremity reperfusion without delaying central aortic repair, thereby minimizing ischemia-reperfusion injury while ensuring definitive aortic management.

PurposeTo reduce and avoid the use of exogenous blood products for neonates and infants, our center limits the use of packed red blood cells and does not use fresh frozen plasma in our cardiopulmonary bypass (CPB) circuit primes. This practice has resulted in several bloodless neonatal open heart surgical procedures including the entire post operative hospital stays. This case report describes a patient with Hypoplastic Left Heart Syndrome who underwent the Norwood procedure without the use of exogenous blood products. No other report of a bloodless Norwood procedure could be found in the literature.MethodsMiniaturized cardiopulmonary bypass circuitry, including shortened arterial and venous lines, minimized modified ultrafiltration and cardioplegia circuits, low holdup volume vents and autologous bypass circuit priming, was used to preserve adequate oxygen carrying capacity at CPB initiation and during the entire surgical procedure.OutcomeNo exogenous blood products were administered to this patient during their entire hospitalization.

We report a case of successful treatment for a severe acute pulmonary hypertension crisis in a patient with Eisenmenger syndrome (ES) associated with patent ductus arteriosus following trauma-related spine surgery, utilizing both veno-arterial (V-A) and veno-venous (V-V) ECMO. The patient's clinical course was complicated by right ventricular failure amid a pulmonary hypertensive crisis, necessitating V-A ECMO support. Persistent hypoxia, despite improved right heart function, warranted transition to V-V ECMO. This case demonstrates that peripheral V-A ECMO can be safely employed to decompress the right heart in the presence of a significant PDA shunt. Furthermore, weaning from ECMO in these patients requires a much higher hematocrit in order to compensate for the chronic hypoxia.

BackgroundIn-situ internal mammary artery (IMA) grafting remains the gold standard in coronary artery bypass grafting (CABG), particularly for left anterior descending artery revascularisation. However, the role of free-IMA grafts-especially free right IMA (RIMA) and select cases of free left IMA (LIMA)-has expanded in response to anatomical and technical constraints. This narrative review synthesises current evidence on free-IMA use during CABG.MethodsA structured literature search was conducted using PubMed (1946-2025) and Embase (1974-2025), supplemented by Web of Science, Google Scholar, and thesis repositories. Studies were included if they reported outcomes related to free-IMA grafting, regardless of pump status or harvesting technique. Of 74 eligible studies, 9 chosen studies specifically reported free-RIMA outcomes and were analysed in detail.ResultsFree-RIMA grafting demonstrated excellent long-term patency (up to 96%) and favourable survival outcomes when used as composite or direct aorto-coronary grafts. Multi-arterial grafting (MAG) and total arterial grafting (TAG) strategies incorporating free-IMA conduits were associated with reduced major adverse cardiac events (MACE) and improved freedom from repeat revascularisation. Despite these benefits, uptake of free-IMA techniques remains low in Europe and North America, often limited by institutional preferences and operator experience.ConclusionCurrent evidence supports the selective use of free-IMA grafts in CABG, particularly when in-situ deployment is not feasible. Prospective studies are needed to validate long-term outcomes beyond 10 years, compare free-IMA with radial artery grafts, and define optimal arterial configurations for durable revascularisation.

IntroductionIn patients with prior valve replacement requiring venoarterial extracorporeal membrane oxygenation (VA ECMO), there is a risk of prosthetic valve thrombosis (PVT) due to intracardiac stasis. We describe our experience with PVT in patients on VA ECMO.MethodsThis was a retrospective cohort study of patients with prior valve replacement undergoing VA ECMO. Patients who developed PVT on VA ECMO were compared to those who did not.ResultsForty-six patients who had prior valve replacement (total of 63 valves) were placed on VA ECMO. Six patients (13%) suffered PVT on VA ECMO. There was no difference in the rate of PVT in mitral versus aortic valve prostheses (22% [5/23] vs 3% [1/32]; = .07) or between tissue and mechanical valves (16% [8/50] vs 0% [0/13]; = .19). There were no differences in ECMO parameters, including site of cannulation (central vs peripheral), initial ECMO flow, time to initiation of anticoagulation, or use of a concomitant IABP between patients who did and did not develop PVT. Patients who developed PVT demonstrated significantly lower pulse pressures compared to those who did not (12.7 mmHg vs 32.7 mmHg; = .03). Surgical thrombectomy was performed in three of the six patients with PVT and one survived to discharge.ConclusionPVT occurred in 13% of patients on VA ECMO after prior valve replacement. The only predictor of PVT on VA ECMO was a lower pulse pressure. Strategies to maintain intracardiac flow and pulsatility may reduce this risk. Treatment options are limited and pose significant risk, and therefore prevention is key.

IntroductionHeparin is usually added to infant cardiopulmonary bypass circuit primes. Ultrafiltration is often used to minimise prime volume before commencing bypass. The extent of heparin removal from bypass primes by ultrafiltration is unknown, however at our institution it was assumed that heparin is freely filtered. The primary aim of this study was to investigate heparin removal during pre-bypass ultrafiltration of a bypass prime for infants. The secondary aim was to investigate the effect of pre-bypass ultrafiltration on heparinization of the patient shortly after commencing bypass.MethodsPatients under 1 year of age having cardiopulmonary bypass were enrolled. Prime solutions contained red blood cells, albumin, PlasmaLyte and 3 IU/ml heparin prior to pre-bypass ultrafiltration. Patient blood samples were collected before and after commencing bypass along with samples of the filtrate and the priming solution. Anti-Xa and antithrombin levels were measured by chromogenic assay.ResultsNineteen patients were enrolled. Patient weight ranged from 2.4 kg to 7.7 kg. Anti-Xa in the filtrate was 0.94 IU/ml (IQR 0.84 to 1.06 IU/ml). Anti-Xa in the primes was 6.80 IU/ml (IQR 6.68 to 7.84 IU/ml). Anti-Xa once on bypass was 3.31 IU/ml (IQR 2.08 to 4.46 IU/ml). Antithrombin level on bypass was 38 % (IQR 26 to 57 %). On bypass anti-Xa level was associated with patient weight and antithrombin level but not with activated clotting time.ConclusionsHeparin is not freely filtered from the prime, leading to more heparin being present in the prime than desired. Anti-Xa levels on commencing bypass appear to be predictably influenced by hemodilution such that the gap between total heparin present and anti-Xa activity is wider in smaller patients. The activated clotting time does not differentiate lower levels of anti-Xa activity in the setting of extreme haemodilution.

IntroductionSystemic anticoagulation (AC) is standard practice in extracorporeal membrane oxygenation (ECMO). Adults on ECMO have been successfully managed AC-free. However, slower flow rates in pediatric circuits have mostly prevented this strategy. Thus, ECMO is often avoided in children with intractable hemorrhage.Case ReportA 12-year-old female with microscopic polyangiitis was admitted with diffuse alveolar hemorrhage and acute on chronic renal failure requiring venovenous (VV)-ECMO and continuous kidney replacement therapy (CKRT). Systemic AC was withheld entirely, and the CKRT circuit was regionally anticoagulated with citrate. High ECMO flow rates and positioning of the CKRT return line pre-oxygenator enabled an effective AC-free VV-ECMO run of 15 days.DiscussionThis highlights an innovative approach to a rare but successful pediatric VV-ECMO run without systemic AC in conjunction with regional AC for CKRT.ConclusionAlterations to ECMO circuitry including high flow rates and regional anticoagulation may liberalize candidacy for children with hemorrhage.

A 44-year-old male with pulmonary sarcoidosis related interstitial lung disease and pulmonary hypertension was admitted for pre-transplant evaluation. During hospitalization, he developed cardiac arrest due to worsening respiratory failure and was immediately placed on veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). Despite initial improvement, he developed differential oxygenation, which was managed by converting the support to veno-venoarterial (VVA) ECMO. However, pulmonary artery pressure increased, placing a greater load on the right ventricle, and oxygenation remained inadequate, leading to further optimization of the ECMO settings. The support was switched to veno-pulmoarterial (VPA) ECMO, which improved oxygenation and, through the combined effects of oxygenation and circulatory support, stabilized his condition. After 24 days of ECMO support, the patient underwent successful lung transplantation. His postoperative course was uncomplicated, and he was discharged on postoperative day 32. Over the subsequent 2 years of follow-up, he has remained active, independent of oxygen, and free of functional limitations.

IntroductionExtracorporeal membrane oxygenation (ECMO) can cause blood water loss due to insensible perspiration via oxygenators and plasma leakage. The accurate quantification of water loss is crucial for maintaining fluid balance in patients on ECMO. Although several studies have experimentally investigated water loss in ECMO, the factors influencing this loss and the methods for measuring plasma leakage-related water loss remain uninvestigated.MethodsIn this study, we incorporated a fluid replacement set into a closed circuit and examined the effects of circulating fluid temperature, oxygenator pressure, and gas flow rate on insensible water loss via an oxygenator. Furthermore, we measured water loss due to plasma leakage by circulating pure water and a solution with a lower surface tension than that of healthy human plasma in the same circuit.ResultsOur findings revealed that insensible water loss from the oxygenator was significantly influenced by the circulating fluid temperature and gas flow rate, but was not affected by the oxygenator pressure. Additionally, the difference in water loss between pure water and the low-surface-tension solution accurately represented the water loss due to plasma leakage.ConclusionsWater loss from the oxygenator depends on the temperature and gas flow, and plasma leakage can be quantified by accounting for the insensible loss in a closed-loop system.

PurposeChatbots have enhanced student engagement and learning outcomes in education. Simulation-based training is critical in perfusion education, providing risk-free environments for skill mastery and clinical readiness. This research aimed to assess whether a chatbot (PerfusionPal) impacted students' learning outcomes.MethodsThis pilot randomized, controlled trial, conducted in 2024, included 21 university students enrolled in the Cardiovascular Perfusion Master's Program. Students were randomly assigned to the experimental group, receiving the PerfusionPal intervention, or the control group, without PerfusionPal. Two simulated scenarios were utilized. The primary outcome was pre-simulation and post-simulation assessment scores.ResultsIn simulation 1, there were no significant differences between the control and experimental groups in pre- and post-simulation assessment scores ( = 0.539 and = 0.276, respectively), completion time ( = 0.197), or the number of reservoir checks ( = 0.072). However, the experimental group had significantly longer average times between reservoir checks compared to the control group ( = 0.036). In simulation 2, no significant differences were found in pre- and post-simulation assessment scores ( = 0.832 and = 0.605, respectively), completion time ( = 0.350), or number of reservoir checks ( = 0.061). The experimental group showed significantly higher average times between reservoir checks ( = 0.043).ConclusionThis pilot study found that although the PerfusionPal chatbot did not significantly improve assessment scores or simulation performance, it influenced reservoir monitoring. More research is needed to optimize its integration into simulation training and to assess its feasibility and generalizability.

IntroductionCardiopulmonary bypass (CPB) plays a central role in pediatric cardiac surgery, yet standardized quality indicators (QIs) specific to pediatric practice remain underutilized across institutions.MethodsA comprehensive review of literature from 2010 to 2025 was conducted using PubMed, Embase, and the Cochrane Library. Eligible studies included randomized trials, observational research, and meta-analyses.ResultsDOi > 340 mL/min/m in neonates and >400 mL/min/m in infants was associated with a lower risk of acute kidney injury (AKI). Lactate >3 mmol/L predicted major morbidity, while MAP >40-45 mmHg correlated with adequate perfusion. Maintaining Hct ≥25% and a fluid balance within ±5% of baseline also supported improved postoperative outcomes. The integration of real-time multimodal monitoring, including NIRS and venous oxygen metrics, enhances individualized perfusion management.ConclusionAdopting and standardizing QIs in pediatric CPB supports early detection of inadequate perfusion and enhances surgical safety. A structured, multimodal QI framework can facilitate institutional benchmarking, improve patient outcomes, and guide future innovation in pediatric perfusion practices.

AimTo characterize the impact of BMI (body mass index) on HIBI (hypoxic-ischemic brain injury) in patients receiving ECPR, with the hypothesis that elevated BMI is associated with increased risk of HIBI.MethodsThe Extracorporeal Life Support Organization (ELSO) registry was queried for patients who received ECPR during 2020-2024. Patients were categorized into 5 standard BMI groups. Normal Weight was used as the reference group. Generalized additive model (GAM) analysis was performed to identify the BMI range with greatest predicted HIBI risk. Multivariable logistic regression was used to compare odds of HIBI and post-HIBI mortality between standard BMI groups and Normal Weight.ResultsOf 6413 included patients (median age = 57.4, 68.6% male, median BMI = 28.1), 10.5% of Class 1 Obesity patients experienced HIBI compared to 5.0% of Normal Weight patients, 9.6% of Class 2 Obesity patients, 6.3% of Overweight patients, and 3.6% of Underweight patients ( < 0.001). GAM analysis showed a non-linear relationship between BMI and HIBI with highest predicted HIBI risk for Class 1 Obesity patients, which was confirmed by multivariable regression (adjusted odds ratio (aOR) = 1.86, 95%CI = 1.09, 3.20, = 0.02). HIBI led to >90% mortality in all BMI categories, with increased odds of post-HIBI mortality for Class 1 Obesity patients compared to Normal Weight (aOR = 1.97, 95%CI = 1.14, 3.47, = 0.016). There was no significant difference in odds of HIBI or post-HIBI mortality for any other BMI category compared to Normal Weight.ConclusionsECPR patients with Class 1 Obesity had increased odds of HIBI and post-HIBI mortality compared to Normal Weight patients after adjusting for covariates.

BackgroundVeno-pulmonary artery extracorporeal membrane oxygenation (V-P ECMO) is a configuration of extracorporeal life support (ECLS) for patients with isolated or predominantly right ventricular (RV) failure and inadequate gas exchange due to severe respiratory failure. We aimed to systematically review the existing literature to better understand its utilization patterns and associated outcomes.MethodsThe electronic search identified all studies reporting the characteristics and outcomes of V-P ECMO use in adult patients. Patient-level data for 110 patients from 60 case reports and case series were extracted and analyzed.ResultsThe median patient age was 45 [IQR, 32-56] years, and 63% were male. Patients most commonly presented with moderate to severe RV dysfunction (90%), along with acute hypoxic respiratory failure (64%) and severe pulmonary hypertension (23%). On presentation, 85% of patients were placed on ventilatory support for a median duration of 13 [5-32] days. V-P ECMO was initiated in the setting of a primary cardiorespiratory pathology in 75% of cases, and major chest surgery in 25% of cases. A percutaneous dual-lumen cannula was used in 64% of cases, of which 29% required an additional cannula. The median duration of V-P ECMO support was 12 [7-31] days. Overall, 42% of patients recovered, 26% underwent lung transplantation, and 9% underwent heart transplantation. In-hospital mortality was 22%. At a median follow-up time of 81 [44-181] days, overall survival was 75%.ConclusionV-P ECMO can be utilized in place of traditional ECLS strategies with favorable outcomes across various settings.