Abstract Introduction Coagulopathy is frequent in refractory out-of-hospital cardiac arrest (OHCA) patients treated with extracorporeal cardiopulmonary resuscitation (ECPR), yet its prognostic significance and heterogeneity remain poorly characterised. Objectives To characterize coagulopathy at ECPR initiation, identify coagulation phenotypes, evaluate their association with outcomes, and describe their temporal evolution. Methods All consecutive refractory OHCAs treated with ECPR (2013–2024) were included. Phenotypes were identified by unsupervised K-means clustering on PT-INR, aPTT, platelets, antithrombin, fibrinogen, and D-dimer measured at ECPR initiation. Associations with survival, neurological outcomes, and complications were assessed by multivariable logistic regression. Results Of 406 ECPR patients, 360 had coagulation data for analysis (initial shockable rhythm 67%, low-flow 70 min [IQR 58–81]). Three phenotypes were identified: severe consumptive coagulopathy (phenotype 1, n=49, 13.6%), mild consumptive coagulopathy (phenotype 2, n=175, 48.6%), and preserved coagulation (phenotype 3, n=136, 37.8%). Phenotype 1 had no survivors, compared with survival of 8.6% and 33.1% in phenotypes 2 and 3, respectively; favourable neurological outcome was achieved in 0%, 5.1%, and 17.6%. Phenotype severity correlated with ischaemic burden (lactate, arterial pH, end-tidal CO2, and low-flow duration). On multivariable analysis, phenotype 2 was associated with lower survival (OR 0.25, 95% CI 0.12–0.55) and favourable neurological outcome (OR 0.31, 95% CI 0.12–0.81) versus phenotype 3. Bleeding incidence rates were 38, 12, and 2.5 events per 100 patient-days in phenotype 1, 2, and 3, respectively (all p < 0.001). Conclusions Three distinct coagulation phenotypes at ECPR initiation were independently associated with survival and neurological outcome and appear to reflect ischaemic injury severity. These findings require validation in independent cohorts before clinical application.
Abstract Background Acute decompensated severe aortic stenosis may preclude waiting for elective treatment, and evidence for non-elective transcatheter aortic valve implantation (TAVI) is limited. We assessed 12-month mortality, 30-day safety, and recovery after urgent, emergency, or salvage TAVI. Methods We prospectively enrolled patients undergoing urgent, emergency, or salvage TAVI at one centre in 2022–2025. The primary endpoint was 12-month all-cause mortality; secondary endpoints included device success, 30-day safety, and functional and echocardiographic recovery. Results Among 53 patients, 36 underwent urgent, 14 emergency, and 3 salvage TAVI. Device success was 52/53 (98.1%). Thirty-day mortality was 1/36, 0/14, and 0/3; 12-month mortality was 2/36, 1/14, and 0/3 (3/53). Kaplan–Meier 12-month survival was 94.3% (95% confidence interval 83.5–98.1%). New atrioventricular block was detected in 2/53 on postoperative day 2; by 30 days, haemofiltration or renal replacement therapy occurred in 1/53 and permanent pacemaker implantation in 0/53. At 12 months, cardiovascular mortality was 2/53, heart-failure readmission 4/53, stroke 1/53, a separate Valve Academic Research Consortium-3 type 2 bleeding event 1/53, and permanent pacemaker implantation 0/53. Paired analyses showed improved New York Heart Association class, Kansas City Cardiomyopathy Questionnaire-12, left ventricular ejection fraction, and transvalvular gradients at 30 days and 12 months (all P<0.001). Conclusions Selected patients had high device success and low early event rates after non-elective TAVI; paired data showed sustained functional and haemodynamic improvement. These findings support timely Heart Team assessment and consideration of non-elective TAVI, when appropriate, at experienced centres; comparative benefit over alternative strategies warrants prospective study.
