Survival with acute cardiopulmonary failure remains a formidable challenge despite advances in mechanical circulatory support (MCS). Although venoarterial extracorporeal membrane oxygenation (ECMO) provides combined cardiopulmonary support, patients with improving cardiac function and persistent respiratory failure may no longer require arterial ECMO. We describe our early experience using a combine venovenous (VV) ECMO and Impella 5.5 (VVECPella) as a de-escalation strategy in this setting. We report a series of five patients supported with the VVECPella configuration at our institution from January 2025 to January 2026. Impella 5.5 was implanted via axillary, innominate, or direct ascending grafts. Operative details, hospital course, and patient outcomes were retrospectively reviewed. In total, five patients underwent VVECPella support. The most common indication was persistent severe respiratory failure despite improving hemodynamics following cardiogenic shock. Median VV ECMO duration was 4 days (range 1-8), Impella support 6 days (3-15), and combined support 4 days (2-8). Four patients (80%) were successfully weaned from both devices with recovery of cardiac and respiratory function, while one patient died from multiorgan failure. Major hemolysis occurred in 3 patients (60%), whereas vascular complications were attributable to prior VA ECMO cannulation rather than the VVECPella configuration. In conclusion, VVECPella appears to be a feasible de-escalation strategy for carefully selected patients with improving circulatory failure but persistent respiratory insufficiency, allowing independent titration of cardiac and respiratory support while avoiding prolonged arterial ECMO. Larger multicenter studies are warranted.
Early postoperative risk stratification after surgical aortic valve replacement remains challenging in patients with severe aortic stenosis and reduced left ventricular ejection fraction. Although postoperative troponin elevation is expected after open-heart surgery, the discriminatory value of ICU admission high-sensitivity cardiac troponin T (hs-cTnT) in this specific myocardial phenotype remains uncertain. We evaluated whether ICU admission hs-cTnT provides useful early discrimination for 30-day all-cause mortality after surgical aortic valve replacement in patients with severe aortic stenosis and reduced left ventricular ejection fraction and compared its performance with other postoperative ICU biomarkers. We conducted a single-center retrospective cohort study of 184 adults with severe aortic stenosis and left ventricular ejection fraction ≤40% who underwent surgical aortic valve replacement between 2020 and 2024 and had complete 30-day follow-up. ICU admission hs-cTnT was available in 183 patients. Biomarkers included ICU admission hs-cTnT, ICU admission lactate, peak ICU C-reactive protein, and ICU admission B-type natriuretic peptide. Discrimination was assessed using receiver operating characteristic analysis, DeLong comparisons, repeated stratified 5-fold cross-validation, and bootstrap optimism correction. Multivariable models were interpreted as exploratory because of the limited number of mortality events. Thirty-day mortality occurred in 29 of 184 patients (15.8%). ICU admission hs-cTnT showed poor discrimination for 30-day mortality in the hs-cTnT analytic cohort and remained non-discriminatory after repeated cross-validation. In the common four-biomarker cohort, lactate outperformed hs-cTnT by DeLong testing, whereas the four-biomarker model did not significantly improve discrimination beyond lactate alone. Bootstrap optimism correction attenuated the apparent performance of multimarker models, supporting cautious interpretation. Exploratory analyses also suggested that mortality did not increase monotonically across hs-cTnT quartiles. In patients with severe aortic stenosis and reduced left ventricular ejection fraction undergoing surgical aortic valve replacement, ICU admission hs-cTnT did not provide reliable early mortality discrimination. Lactate remained the strongest early individual biomarker, whereas multimarker models showed exploratory discrimination but require external validation. These findings support a phenotype-specific interpretation of postoperative hs-cTnT rather than reliance on universal postoperative troponin assumptions.
Implantable cardioverter-defibrillators (ICDs) are critical for the prevention of sudden cardiac death due to ventricular arrhythmias and are commonly encountered in the perioperative space. Traditional devices contain transvenous leads that are susceptible to mechanical failure or infection. To reduce these complications, two entirely extravascular ICDs are currently approved for implantation: the subcutaneous Emblem MRI S-ICD and the extravascular Aurora EV-ICD. This article provides an evidence-based review of the indications for use, implantation technique, and anesthetic considerations for these novel systems.
