Guru, Pramod

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.

Abstract Background Lung transplantation remains the accepted treatment modality of choice for life-threatening advanced lung disease due to established benefits of improving survival and functional status of the patients. However, the annual mortality of lung waitlist candidates remains high, reflecting ongoing donor-recipient mismatches and prolonged wait times. Modalities such as extracorporeal membrane oxygenation (ECMO) have been effectively used as a “bridge to transplant” (BTT) in high-risk patients on waitlist. Objective To evaluate trends in ECMO utilization, waitlist dynamics, and outcomes among lung transplant candidates between 2018 and 2024, with emphasis on the use of ECMO as a bridge to transplantation. Methods We conducted a retrospective chart review of all ECMO runs performed between 2018 to 2024 at the Mayo Clinic Florida Hospital. Among these, patients who underwent evaluation for lung transplantation were identified, and their waitlisting patterns, transplant outcomes, and peri-transplant ECMO status were described. Results Between 2018 and 2024, a total of 348 ECMO runs were recorded among 293 patients. Annual ECMO runs increased steadily from 17 in 2018 to 83 in 2024 (2019: 33, 2020: 30, 2021: 61, 2022: 56, 2023: 68, 2024: 83). Out of these patients, 142 underwent evaluation for lung transplantation and 133 (93.67%) were placed on the waitlist. Among waitlisted patients, 105 (78.9%) were listed before ECMO initiation, 23 (17.3%) during ECMO, and 5 (3.8%) after decannulation. Waitlist outcomes included 116 (87.2%) transplanted, 16 (12.0%) deaths before transplant, and 1 (0.8%) clinical improvement precluding transplant. Among 116 transplanted patients, 36 patients (31.03%) received ECMO as a bridge to lung transplantation. The annual patients bridged with ECMO demonstrated a progressive rise: 1 (2019), 3 (2020), 9 (2021), 6 (2022), 9 (2023), and 8 (2024). Among these 36 patients, 29 (80.56%) remained on ECMO support in the immediate post-transplant period. At the latest follow-up, mortality among BTT recipients was 9 (25%). Conclusion ECMO utilization has expanded substantially over the past several years reflecting its expanding role in supporting critically ill patients. There has been increased utilization of ECMO as a bridge to lung transplantation in order to support high risk candidates awaiting donor organs. The post-transplant mortality among BTT recipients was 25%, which highlights the importance of peri-transplant management to optimize long-term outcomes in this high-risk cohort. This abstract is funded by: None

ABSTRACT Objective To describe the practice patterns of point‐of‐care ultrasound (POCUS) and compare its usage across subgroups (adult vs. paediatric practitioners, physicians vs. nurse practitioners [NPs], high income [HI] vs. low and middle ‐income [LMI] countries). Methods Survey distributed via the Society of Critical Care Medicine in May–June 2024. Respondents reported the percentage of eligible patients in the past year for whom POCUS was used for vascular access and diagnostic purposes. Responses (0%, < 25%, 25%–50%, 50%–75%, > 75%) were converted into binary categories (> 50% use) and compared across subgroups using logistic regression. Results The survey was completed by 503 respondents from 39 countries (6% response rate): 77.7% from HI countries, 20.9% paediatric practitioners and 18.3% Nurse Practitioner (NPs)/Physician assistants (PAs). POCUS was commonly used for vascular access, and similar usage was found among NP/PAs, physicians, and adult and paediatric practitioners. Practitioners from LMI countries were less likely to use POCUS for vascular access. Basic diagnostic applications, such as assessing pleural effusion (72.5%) and left ventricular function (69.2%), were more commonly used than advanced applications like pulmonary artery pressure measurement (22%). Physicians were more likely than NPs (for some indications), and adult practitioners were more likely than paediatric practitioners (for most indications) to use POCUS for diagnostic purposes. Practitioners in LMI countries reported higher use of diagnostic applications than practitioners in HI countries. Conclusions POCUS is widely adopted in critical care but is less accepted for diagnostic use among paediatric practitioners and NP/PAs. Diagnostic utilisation is higher in LMI countries, while procedural use is lower. Impact Statement Point‐of‐care ultrasound (POCUS) is increasingly used in intensive care units to guide diagnosis and procedures. Despite its importance, little is known about how consistently it is used by different types of clinicians around the world. This international survey of critical care practitioners from 39 countries shows that POCUS is widely used, particularly for procedures, but diagnostic use remains uneven. Paediatric clinicians and advanced practice providers report lower diagnostic use, while clinicians in low‐ and middle‐income countries report higher diagnostic adoption. These findings highlight opportunities to improve access to training and support broader, more equitable use of POCUS in critical care.

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.

Backround: Atrial fibrillation (AF) is a common complication following veno-venous extracorporeal membrane oxygenation (VV-ECMO), leading to further complications from anticoagulation or stroke. The Artificial Intelligence AF Prediction Dashboard developed at Mayo Clinic generates two predictive outputs: (1) a continuous probability score and (2) a binary threshold-based signal to predict the likelihood of AF at an individual level after 12-lead electrocardiogram (ECG) is obtained. Using both continuous risk (%) and binary (yes/no) likelihood, we present a novel method to understand AF risk after VV-ECMO cannulation based on pre-ECMO 12-lead ECG. Methods: We reviewed a total of 147 patients on ECMO between 2018 and 2024, from which 85 VV-ECMO patients with complete data were included. AI Dashboard outputs were quantified as binary (1/0) or percent likelihood for AF. R was utilized for statistical analysis. Results: 85 patients met our inclusion criteria from which AF after cannulation occurred in 31 (36%). 17 patients had a history of AF prior to VV-ECMO initiation. The mean age of our cohort was 49 years with a mean BMI of 29.3. Baseline AI Dashboard continuous assessment identified 39 patients (46%) compared to the binary assessment identifying 31 patients (36%). Logistic regression in the binary assessment demonstrated an odds ratio of 1.08 (95% CI 1.04 – 1.12) with a p value of <0.001. The binary AF Prediction yielded a 58% sensitivity, 76% specificity, 58% PPV, and 76% NPV, with an accuracy of 67%. The continuous AF Probability score achieved 72% balanced accuracy with sensitivity 74%, specificity 70%, PPV 59% and NPV 83%, indicating fair overall performance and suggesting good utility for ruling out AF in low-risk patients. Although both outputs provided moderate predictive accuracy, the continuous score reported before ECMO cannulation demonstrated stronger overall performance with fewer false negatives and higher rule-out value. Conclusions: We demonstrate the novel use of an AI predictive model in the VV-ECMO population for the prediction of AF risk with both continuous and binary risk cutoffs from baseline ECG. This data highlights the need for further development in ECMO-specific AI models to help mitigate risk after the onset of atrial arrhythmias. As AI-driven tools become increasingly integrated into care, their performance must be continuously validated and recalibrated for specific populations to ensure their safe and effective use.