Bhattacharyya, Anirban

Emerging evidence links veno-venous extracorporeal membrane oxygenation (VV-ECMO) to right ventricular (RV) dysfunction, but the relative contribution of ECMO versus underlying disease progression remains unclear. We conducted a multicenter, retrospective, propensity-matched study including 408 intubated acute respiratory distress syndrome (ARDS) patients who were admitted between January 2020 and October 2024 in a quaternary referral hospital network within the United States and underwent at least two transthoracic echocardiograms (TTEs) after intubation. Using 1:2 propensity score matching, we adjusted for baseline comorbidities, baseline hemoglobin, lactate, and worst PaO 2 /FiO 2 ratio (P/F). Longitudinal echocardiographic changes were analyzed with a cumulative link mixed model (CLMM), evaluating RV size and function as ordinal outcomes. Within 408 patients (112 received ECMO support), propensity matching identified 55 ECMO and 110 non-ECMO patients with balanced baseline characteristics. Among 469 serial echocardiograms, RV size and function worsened more frequently in ECMO patients. In longitudinal modeling, ECMO use alone was not associated with RV dilation ( p = 0.23) or dysfunction ( p = 0.43). However, longer ECMO duration was associated with RV dilation (OR: 1.04 per day, p = 0.004) and dysfunction (odds ratio [OR]: 1.04 per day, p < 0.001). Higher ECMO circuit flow had a trend toward progressive RV dilation and dysfunction but did not reach statistical significance. These findings highlight the need for vigilant RV monitoring during ECMO support.

The Omicron variant of SARS-CoV-2 is associated with milder symptoms and lower hospitalization and mortality rates than Delta variants, although the impact of Omicron on immunocompromised patients, especially solid organ transplant (SOT) recipients, is still unclear. This study compares the hospitalization rate and outcomes between immunocompromised, immunocompetent, and SOT patients during the Delta and Omicron periods. We included adult patients who tested positive for SARS-CoV-2 on PCR or nasopharyngeal antigen test between 26 June 2021 to 8 September 2022, at our institution. A total of 12,401 COVID-19 patients were included, of which 11,055 were immunocompetent, and 1346 were immunocompromised (375 SOT recipients). Throughout the Delta and Omicron outbreaks, immunocompromised patients exhibited higher comorbidities and 30-day hospitalizations, but rates of mechanical ventilation and ICU-level care were like immunocompetent patients. During the Omicron wave, immunocompromised patients had higher unadjusted relative risk estimates (RR = 2.37, 95% CI 1.96–2.87, p < 0.05) than Delta (RR = 1.58, 95% CI 1.24–2.01, p < 0.05), with higher adjusted relative risk for hospitalization in Omicron (RR = 1.50, 95% CI 1.10–2.03, p = 0.01). Analyses show increased hospitalization risk in immunocompromised during the Omicron wave compared to the Delta wave, with no significant difference in hospitalization outcomes. The relative risk of hospitalization for SOT patients was higher in both waves.

ABSTRACT Introduction Extracorporeal membrane oxygenation (ECMO) is a life‐saving intervention for refractory cardiopulmonary failure. Despite advancements reducing complications, ECMO remains associated with acute kidney injury (AKI), often requiring kidney replacement therapy (KRT). Studies report up to 45% of ECMO patients needing KRT, significantly increasing mortality. A prior meta‐analysis suggested a declining mortality trend in recent years. Methodology Following PRISMA guidelines, PubMed, MEDLINE, EMBASE, and Cochrane Library were searched (2000–2024) for randomized and observational studies on adult ECMO patients requiring KRT. Data extraction covered study characteristics, patient demographics, ECMO type, KRT timing, and clinical outcomes. Quality was assessed using the Newcastle–Ottawa Scale. Statistical analyses were performed using RevMan 5.4.1 under a random‐effects model, with mortality as the primary outcome. Result A total of 24 studies (6347 patients) met the inclusion criteria, including 23 observational studies and one RCT. The mean age of ECMO + KRT patients was 51 years in observational studies and 61.2 years in the RCT, with cardiogenic shock as the most common ECMO indication. Meta‐analysis showed a significantly higher mortality in ECMO + KRT patients (RR: 1.86, 95% CI: 1.63–2.12, p < 0.001), with infections and bleeding as key contributors. Subgroup analysis revealed no significant survival difference based on KRT timing, while Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) was associated with worse outcomes than Veno‐venous extracorporeal membrane oxygenation (VV‐ECMO). The RCT reported 61.9% mortality at 30 days in ECMO + KRT patients. Conclusion KRT during ECMO is associated with increased mortality, likely due to the severity of illness and complications like infections and bleeding. The optimal timing of KRT initiation remains unclear, and no significant survival benefit was found for early KRT. Further large‐scale RCTs are needed to optimize management strategies.

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.

Problem Statement: The prognostic value of troponin elevation in septic ICU patients without known history of cardiac disease remains unclear, particularly after accounting for overall illness severity. Background: Minor troponin rises are frequent during sepsis, yet clinicians still lack a clear cut-point that signals danger once cardiac disease is ruled out. We asked whether a modest increase in troponin-T predicts in-hospital death beyond global illness severity. Methods: We studied 1 221 adult first ICU stays labelled “sepsis” in the eICU Collaborative Research Database and removed any case with a cardiac admission diagnosis. Implausible or missing laboratory values were imputed by multiple imputation. Hospital mortality was modelled with logistic regression that included troponin (a continuous and a binary model with threshold > 0.04 ng/mL) together with age, sex, lactate, albumin, BUN, creatinine, intubation status, vasopressor use, dialysis requirement and APACHE-IV predicted mortality. A natural-spline model explored non-linear behavior. Findings were checked in a 1:1 propensity-matched cohort. Results: Overall mortality was 11.7%. Troponin exceeded 0.04 ng/mL in 38% of patients. After adjustment for APACHE-IV probability and other covariates, a troponin level > 0.04 ng/mL was associated with almost twice the odds of death (OR ≈ 1.9), whereas the continuous model suggested only a modest trend (OR ≈ 1.1 per ng/mL). The spline curve rose steeply between 0 and 0.10 ng/mL and flattened thereafter, pinpointing an inflection near 0.05 ng/mL. Matching on all measured confounders confirmed that high-troponin patients had about three-fold greater mortality (OR ≈ 2.8, 1.55-5.05; p<0.001), highlighting that even modest troponin elevation is an independent risk marker for death in septic ICU patients. A bedside heat-map combining troponin, albumin and need for intubation illustrated a simple gradient: risk climbs from 2 % in low-troponin, well-albuminised, non-intubated patients to nearly 7 % when troponin exceeds 0.10 ng/mL in intubated, hypo-albuminemic patients. Conclusions: Even modest troponin elevations (> 0.04 ng/mL) independently predict mortality in sepsis after rigorous adjustment and matching on APACHE-IV physiology, lactate, and organ-support variables. This biologic threshold supports incorporating troponin into bedside triage and future septic cardiomyopathy trials.

Background: Progressive heart failure cardiogenic shock (HFCS) often requires escalation to temporary or durable mechanical circulatory support (MCS) as a bridge to transplant (BTT). Following the 2018 UNOS allocation changes, our center revised its BTT strategy to optimize support and shorten wait times. At our institution, the Impella 5.5 with SmartAssist via the axillary approach was selectively used for patients who remained refractory to guideline-directed medical therapy, failed single-inotrope therapy, and were not considered suitable durable LVAD candidates by our multidisciplinary heart team. We compared transplant-related outcomes of BTT patients supported with Impella 5.5 versus durable LVAD. Methods: We performed a single-center retrospective review of all heart and heart/kidney transplant candidates at Mayo Clinic Florida from October 2018 to February 2021. INTERMACS profile, baseline characteristics, and perioperative data were collected at the time of device implantation and throughout the transplant hospitalization. Results: A total of 87 heart and 4 heart–kidney transplants were completed. Forty-five patients (49%) required MCS as BTT: 27 (60%) with a durable LVAD and 18 (40%) with an Impella 5.5. All eighteen patients with Impella 5.5 as BTT (100%) were transplanted compared to nineteen patients with durable LVAD (70%), p = 0.001. The median time from listing to transplant was substantially shorter with Impella (32 vs. 696 days, p < 0.001), and this difference persisted across INTERMACS profiles. UNOS status at transplant was more urgent for Impella than LVAD (p < 0.001). Transplant surgery following Impella support required shorter cardiopulmonary bypass time (181 vs. 219 min, p < 0.001) and resulted in lower postoperative vasoactive-inotropic requirements (7.9 vs. 13, p = 0.003). No patients in the Impella group died or were delisted while awaiting transplant, whereas 5 LVAD patients (26%) died or were removed due to LVAD complications (p < 0.001). Conclusions: Our data demonstrates that the use of the Impella 5.5 as BTT was associated with significantly shorter waitlist time, higher transplantation rates, reduced perioperative morbidity, and lower postoperative vasoactive support compared with durable LVAD as BTT. These benefits were achieved despite a higher severity of illness at transplantation in the Impella cohort.

Abstract Rationale: Mechanical circulatory support (MCS) devices, including Extracorporeal Membrane Oxygenation (ECMO) and Impella are essential in managing complex heart transplant cases. Identifying predictors for MCS utilization can improve patient selection and perioperative planning. This study aims to refine MCS allocation by analyzing pre-transplant predictors for each device, thereby optimizing clinical decision-making in critical care. Methods: This retrospective study included 594 heart transplant patients from 2019-2024 (mean age: 63 ± 1.41 years, 29% female, mean left ventricular ejection fraction (LVEF): 36.5 ± 33.23%, mean body mass index (BMI): 32.23 ± 4.497 kg/m²). Variables assessed included age, gender, BMI, smoking status, comorbidities (e.g., chronic kidney disease, hypertension, diabetes), heart failure etiology, and hemodynamic parameters (cardiac index, LVEF, PAPi). Multivariate logistic regression models estimated odds ratios (OR) and 95% confidence intervals (CI) for the likelihood of ECMO and Impella use based on pre-transplant variables. Results: 1. ECMO Use: ECMO was significantly associated with younger age (&lt;40 years), elevated pulmonary artery pressure (PAPi &lt;1.5; OR = 2.70, 95% CI: 1.13-6.48), and reduced cardiac index (&lt;2.2 L/min/m²; OR = 3.12, 95% CI: 1.50-6.49). Male patients also had a higher likelihood of ECMO requirement (OR = 0.54, 95% CI: 0.29-1.00). These findings suggest ECMO may be required for younger, hemodynamically compromised patients. 2. Impella Use: Impella use was significantly associated with smoking history (OR = 3.72, 95% CI: 1.71-8.58), hypertension (OR = 2.08, 95% CI: 1.02-4.43), and low baseline LVEF (&lt;25%; OR = 2.20, 95% CI: 1.18-4.07). Patients with chronic kidney disease or diabetes also had increased odds of requiring Impella, indicating its relevance for high-risk patients with vascular or metabolic burdens. Conclusions: This study identifies distinct pre-transplant predictors that influence MCS allocation in heart transplant patients. ECMO is associated with younger age and lower cardiac index, while Impella is more likely to be used in patients with vascular or metabolic comorbidities. These insights can enhance precision in MCS allocation, supporting optimal outcomes in critical care management.