Banker, Himanshi

Extracorporeal membrane oxygenation (ECMO) use during liver transplantation is a complex and evolving aspect of critical care. This retrospective analysis presents the largest North American case series to date, offering a detailed comparison of survival outcomes in liver transplant (LT) patients supported by ECMO. A total of 15 patients were supported with ECMO, eight were supported on venoarterial (VA) ECMO and the remaining seven on venovenous (VV) ECMO. The median duration of ECMO support was 10 days. Mean intensive care unit (ICU) and hospital stays were 34.8 (interquartile range [IQR]: 1–158) and 49.2 days (IQR: 1–121), respectively. Overall survival was 33.3%, comparable to published rates (20–30%). Survival was based on ECMO initiation timing: preoperative 33.3% (1/3); intraoperative 50% (3/6); postoperative, 16.6% (1/6). All the patients (five) discharged from hospital were alive at 1 year follow-up. Significant ECMO-related complications included acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) (40%, n = 6/15), neurological complications (40%, n = 6/15), and bleeding requiring transfusion (26.6%, n = 4/15). Literature review suggests better outcomes with intraoperative or postoperative ECMO. While ECMO use is increasing in LT, outcomes remain poor. Improved survival may depend on careful patient selection, optimal timing of initiation, and distinguishing reversible pathology from irreversible one.

Background: MELAS is a rare mitochondrial disorder characterized by multisystem involvement, including stroke-like episodes, seizures, and cardiomyopathy. Cardiac involvement in MELAS may include left ventricular dysfunction, arrhythmias, and structural abnormalities, yet the occurrence of cardioembolic stroke as a direct consequence of these manifestations is exceedingly rare. To date, no literature has clearly described this association. Case Presentation: A male in his twenties with known MELAS syndrome, epilepsy, and heart failure with reduced ejection fraction (EF 25%) presented with acute right hemiparesis and aphasia. Investigations: CT angiography and CT perfusion revealed reduced opacification in the left MCA bifurcation and a left M2 thrombus (Figure 1A). The contrast echocardiogram showed a normal-sized left ventricle with severely reduced ejection fraction (25%, down from 30% six months prior), diffuse hypokinesis, grade III diastolic dysfunction, and a left ventricular thrombus, with no patent foramen ovale. Treatment: Given the high suspicion for cardioembolic stroke, the patient received intravenous tenecteplase within the 3-hour window. Mechanical thrombectomy was planned but aborted due to spontaneous recanalization. Post-thrombolytic angiography confirmed reperfusion of the left MCA with residual distal M3 thrombus (Figure 1B).MRI confirmed infarcts in the left MCA distribution and right precentral gyrus, with no evidence of hemorrhagic transformation. Anticoagulation was initiated for secondary prevention. Statins were withheld due to concerns about mitochondrial toxicity. Follow-up: On a 3-month follow-up, the patient remained neurologically stable and continued oral anticoagulation without recurrent events. Discussion: The clinical scenario posed a diagnostic challenge—stroke-like episodes in MELAS are metabolic and typically non-territorial. However, an LV thrombus, territorial infarction, and perfusion mismatch pointed to an ischemic etiology. Timely thrombolysis led to significant neurological recovery. This case highlights the importance of distinguishing cardioembolic stroke from mitochondrial stroke-like events, especially in patients with known cardiac involvement. Conclusion: In MELAS patients with cardiac dysfunction, cardioembolic stroke must be considered when clinical and imaging findings suggest a vascular event. Early recognition and intervention, including thrombolysis, can lead to favorable outcomes.

Introduction: Cardiopulmonary bypass time (CPBT) and aortic cross-clamp time (AXCT) are independently associated with postoperative morbidity and mortality. However, no universally accepted “optimal” duration exists, as these times are influenced by the complexity of cardiac surgery. ECMO is being increasingly used for cardiogenic shock in patients undergoing cardiotomy, but the impact of CPBT and AXCT on outcomes in this specific population remains unexplored. This study investigates how CPBT and AXCT influence outcomes in cardiotomy patients on ECMO support. Research Question: Do CPBT and AXCT influence mortality and complication rates in cardiotomy patients receiving ECMO support? Methods: We conducted a retrospective chart review (Jan 2020–Dec 2024) across a multidisciplinary North American practice, identifying 623 patients who required ECMO. Of these, 236 (37.8%) received ECMO in the preoperative, intraoperative, or postoperative period of cardiotomy. Patients were grouped by prolonged CPBT (>150 min) vs standard (≤150 min) and prolonged AXCT (>90 min) vs standard (≤90 min). We analyzed outcomes including 30-day mortality, ECMO characteristics, and postoperative complications. Results: Among the 236 patients, the average age was 60.8 years, BMI 37.43 kg/m 2 ; 63% were male, 85% White. Prolonged CPBT and AXCT were associated with higher BMI (p=0.02, 0.03), prior cardiac surgery (p<0.001, 0.006), and combined CABG+AVR procedures (p=0.01, 0.001). Patients with prolonged durations were more likely to require postoperative ECMO (p=0.001, 0.03). Complications such as mediastinal bleeding, AKI requiring CRRT, mediastinitis, bacteremia, and pneumonia, showed significant association with increased CPBT whereas prolonged AXCT was only linked with mediastinal bleeding. CPBT and AXCT durations did not significantly affect 30-day mortality, ICU/hospital stay, ECMO duration, or ventilation duration. Independent predictors of 30-day mortality included pre-/intraoperative IABP use (OR 2.19, 95% CI 1.11–4.30, p=0.023), Impella use (OR 0.20, 95% CI 0.03–0.75, p=0.040), post-op intracranial bleeding (OR 5.46, 95% CI 1.43–23.9, p=0.016), and CRRT-requiring AKI (OR 3.24, 95% CI 1.63–6.57, p<0.001). Conclusion: Prolonged CPBT and AXCT were significantly linked to higher rates of postoperative complications such as mediastinal bleeding, CRRT requiring AKI, mediastinitis, and pneumonia along with increased need for postoperative ECMO support, without significantly affecting mortality.

Objective The pattern and timing of palliative care utilisation and end-of-life characteristics in extracorporeal membrane oxygenation (ECMO)-supported patients remain underused. We wanted to share our centre’s experience. Methods This is an institutional review board-approved retrospective study of 45 patients who underwent ECMO at a large ECMO centre in North America between January 2013 and July 2018. Results Only 28.9% of the ECMO patients received in-hospital palliative care consultation at a median of 18 days (IQR 12–31) after hospitalisation and 10.5 days (IQR 1–28) from ECMO initiation. 1-year mortality was high, with 44% dying during hospitalisation and an additional 13% within the following year. Patients experienced prolonged hospitalisations (median hospital length of stay: 39 days, IQR 19–89) and exhibited high rates of tracheostomy (53%) and renal replacement therapy (60%). Most end-of-life cases involved the withdrawal of life-sustaining therapy during ECMO, yet only 53% had a completed living will. Conclusion Our study underscores the need for early initiation of palliative care consultation to enhance symptom management, advance care planning, caregiver support and quality of life for ECMO patients and their families.