Abstract Background Although prophylactic veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may provide hemodynamic stability during high-risk percutaneous coronary intervention (PCI), it is also associated with potential complications and may not be necessary in most cases. In this context, we proposed a pre-cannulated standby ECMO strategy and designed the ECMO-READY trial to evaluate the comparative effectiveness of pre-cannulated standby versus prophylactic ECMO strategies in patients undergoing high-risk PCI. Methods The ECMO-READY trial is a prospective, multicenter, open-label, randomized controlled trial conducted in 8 sites in China. A total of 176 patients scheduled to undergo high-risk PCI will be randomly assigned in a 1:1 ratio to either a pre-cannulated standby ECMO strategy or a prophylactic ECMO strategy. The primary outcome is the 30-day incidence of major adverse events, including death, myocardial, infarction, repeat revascularization, stroke, PCI failure, limb ischemia, major bleeding, vascular injury requiring intervention, and need for renal replacement therapy. Secondary outcomes include post-procedural hemoglobin decline, post-procedural platelet count decline, red blood cell transfusion rate, peak post-procedural interleukin-6 level, use of intra-aortic balloon pump, duration of ECMO support, length of hospital stay, hospitalization cost, and each component of the composite primary outcome. Enrollment began in March 2025 and is anticipated to be completed by December 2026. Discussion The ECMO-READY trial will provide prospective randomized evidence regarding ECMO support strategies in patients undergoing high-risk PCI and may help inform future clinical practice. Trial registration ClinicalTrials.gov NCT06274411 . Registered on February 23, 2024.

This study aimed to investigate the heterogeneity of treatment effect for intra-aortic balloon pump (IABP) across various lactate trajectories in patients with acute myocardial infarction-related cardiogenic shock (AMICS) supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Retrospective data from the China Extracorporeal Life Support Registry included AMICS patients who received VA-ECMO. The latent class growth model was used to identify distinct lactate trajectories. The primary outcome was in-hospital mortality. Baseline characteristics and outcomes were compared across trajectory classes, and the heterogeneity of treatment effect for IABP was assessed. Among 1264 patients, three lactate trajectories were identified. Compared with Class 1, both Class 2 (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.54-2.67) and Class 3 (OR 3.99, 95% CI 2.77-5.78) had significantly higher in-hospital mortality. Moreover, heterogeneity of treatment effect across the classes was found. IABP use was associated with increased risks of in-hospital mortality and multiple complications (bleeding, renal, metabolic, and infection) in Class 1, whereas no associations were observed in Class 2 or Class 3, except for a higher risk of infection in Class 2. In summary, lactate trajectories can stratify mortality risk in AMICS patients receiving VA-ECMO support and reflect heterogeneous responses to IABP treatment.

Background:Mortality after successful weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO) remains common, yet few immune biomarkers enable post-weaning risk stratification. We examined whether circulating CD4⁺ T-cell subsets defined by programmed cell death protein 1 (PD-1) and T cell immunoreceptor with immunoglobulin and immunoreceptor tyrosine-based inhibitory motif domains (TIGIT) were associated with off-ECMO mortality in adults supported with VA-ECMO. Methods:We conducted flow cytometric profiling of circulating T cells in 125 adult VA-ECMO patients, classified as survivors (n = 70), on-ECMO mortality (n = 33), and off-ECMO mortality after successful weaning (n = 22). We first quantified CD3⁺, CD4⁺, and CD8⁺ T-cell counts using BD Trucount tubes, and assessed conventional CD4⁺ and CD8⁺ differentiation subsets by flow cytometry. We then quantified PD-1/TIGIT-defined CD4⁺ T cell subsets and assessed their ability to discriminate off-ECMO mortality among successfully weaned patients using receiver operating characteristic (ROC) analyses with bootstrap resampling. A PD-1/TIGIT-based risk classification was constructed using ROC-derived cut-offs. Results:Although CD3⁺/CD4⁺/CD8⁺ T-cell counts and conventional CD4⁺ differentiation subsets did not differ across outcome groups, the off-ECMO mortality group showed a higher frequency of CD4⁺PD-1-TIGIT⁺ T cells [8.36% (5.65-11.78) vs 5.37% (3.90-7.15), p = 0.005] and a lower frequency of CD4⁺PD-1⁺TIGIT- T cells [10.90% (7.92-14.25) vs 14.95% (10.78-21.85), p = 0.017] compared with survivors. On day 1 of ECMO support, these subsets discriminated off-ECMO mortality with areas under the curve (AUCs) of 0.729 and 0.702, respectively. Based on ROC-derived cut-offs, off-ECMO mortality rates were 10.53%, 16.22%, and 70.59% in the low-, intermediate-, and high-risk groups. Conclusion:A circulating CD4⁺ T cell signature defined by PD-1 and TIGIT expression associates with off-ECMO mortality and may aid risk stratification after VA-ECMO weaning.

Background:Numerous studies have demonstrated that both cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) are often associated with adverse outcomes or immune dysregulation when platelet counts decline during support. Moreover, the severity of thrombocytopenia generally correlates with a worse clinical prognosis. However, the underlying mechanisms remain incompletely understood. Previous research has attributed this phenomenon to hemodynamic alterations during CPB and ECMO, as well as anticoagulant-induced abnormal platelet activation. Based on our clinical observations, we question the completeness of this explanation and propose an alternative hypothesis: sustained platelet activation during ECMO serves as an initiating factor that contributes to both progressive thrombocytopenia and immune dysfunction throughout the support period.Methods:We investigated platelet activation status, degranulation capacity, and T cell subset dynamics in patients receiving ECMO support. Flow cytometry was used to assess platelet surface markers, reticulated platelet proportions, and T cell subset distributions.Results:We demonstrate that platelets exhibit excessive activation during ECMO, accompanied by a gradual decline in their degranulation capacity. Notably, even with an increased proportion of newly formed platelets, this functional impairment persists. Furthermore, we observed significant alterations in Helper T cell Type 1 (Th1) and CD8+ T cell populations during ECMO support.Conclusions:Our findings suggest that aberrantly activated platelets during ECMO amplify the specific recognition of platelet antigens by CD8+ T cells via modulating the differentiation bias of CD4+ T cells, particularly Th1 cells, ultimately leading to platelet depletion. These results suggest that early interventions targeting abnormal platelet activation may represent a potentially effective therapeutic strategy to mitigate ECMO-associated thrombocytopenia.

Background Postoperative respiratory complications remain common after Sun's procedure-based repair for Stanford type A aortic dissection and are associated with adverse early recovery. Whether early postoperative lactate clearance is associated with these complications remains uncertain. Methods In this single-center retrospective cohort study, 118 adult patients who underwent Sun's procedure-based repair for Stanford type A aortic dissection were included. The primary outcome was postoperative respiratory complications within 7 postoperative days. A prespecified multivariable logistic regression model included 6-hour lactate clearance rate (LCR), baseline lactate, cardiopulmonary bypass time, and preoperative PaO 2 /FiO 2 . Receiver-operating characteristic analysis, propensity score matching (PSM), and sensitivity analyses were performed. Results Postoperative respiratory complications occurred in 39 of 118 patients (33.05%). In the primary multivariable model, 6-hour LCR was associated with postoperative respiratory complications (adjusted OR, 0.522 per 10% increase; 95% CI, 0.289–0.874; P = 0.019). The area under the curve (AUC) was 0.769 (95% CI, 0.678–0.859), and the optimal cutoff was 19.45%, with a sensitivity of 0.641 and a specificity of 0.772. In the unmatched median-based grouped analysis, postoperative respiratory complications occurred in 49.15% of the low lactate clearance group and 16.95% of the high group. After PSM using 6 prespecified covariates, the corresponding OR was 2.500 (95% CI, 0.784–7.971; P = 0.121). The 6-hour LCR was inversely correlated with intensive care unit length of stay (Spearman ρ= -0.330; P < 0.001) but was not significantly associated with in-hospital mortality. Conclusion Lower 6-hour lactate clearance after Sun's procedure-based repair for Stanford type A aortic dissection was associated with postoperative respiratory complications in the primary model and in most sensitivity analyses, although the matched analysis was not statistically significant. Early postoperative lactate kinetics may provide hypothesis-generating information for respiratory risk assessment, but further validation in larger prospective and multicenter cohorts is required.

Kidney transplant (KT) patients are susceptible to opportunistic infection, potentially causing severe acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is vital as a life-saving therapeutic approach in reversible cardiopulmonary failure, yet data on its efficacy in this population group are scarce, with only isolated case reports available. This retrospective cohort study enrolled 34 KT recipients through a combined analysis of data from the Chinese Extracorporeal Life Support (CSECLS) registry and Chinese Scientific Registry of Kidney Transplantation (CSRKT), from January 1, 2017, to December 31, 2024. Patients requiring ECMO support in peri-KT period were included. Primary outcome was in-hospital mortality and long-term outcome, as predefined in the registries. Respiratory failure represented the predominant indications for ECMO (85.3%). Patients in the death group exhibited elevated heart rates, lower blood gas pH levels, and necessitated higher doses of inotropic agents compared to the survival group before ECMO. Multivariate analysis revealed that a duration of ≥ 1 year from transplantation to ECMO initiation was significantly linked to decreased likelihood of mortality (HR 0.22; 95% CI, 0.08–0.65, p = 0.006). Conversely, infections, either fungi or virus (COVID-19), were linked to an elevated risk of death (HR 3.30; 95% CI, 1.24–8.81, p = 0.017). ECMO represents a viable strategy for managing reversible cardiorespiratory failure in post-KT recipients. Enhancing the ECMO support capabilities of established organ transplant centers will contribute significantly to the long-term life quality.

BACKGROUND:Post-cardiotomy acute right ventricular failure (aRVF) constitutes a complex clinical challenge that might necessitate escalating interventions, including extracorporeal life support (ECLS). This study evaluated outcomes of adults requiring ECLS for post-cardiotomy aRVF compared with other post-cardiotomy indications. METHODS:In this multicenter, international, retrospective study, we analyzed patients undergoing post-cardiotomy ECLS from January 2000 to December 2020 and compared patients' characteristics and in-hospital mortality between aRVF and other indications. RESULTS:Of 2010 patients, 240 (12%) had aRVF and 1770 (88%) had other indications for ECLS. Demographics were similar between groups; median age was 65 (55-72) years (P = .217), and 60% were male (P = .675). The aRVF group showed higher preoperative right-sided cardiac dysfunction, including preexisting right ventricular failure (aRVF, 22%; other indications, 8%; P < .001) and biventricular failure (aRVF, 12%; other indications, 7%; P = .013). Patients with aRVF more frequently underwent tricuspid valve surgery (aRVF, 20%; other indications, 13%; P = .003) and aortic root procedures (aRVF, 24%; other indications, 13%). They also required longer ECLS support (aRVF, 135 [70-221] hours; other indications, 116 [58-192] hours; P = .025) and longer intensive care unit stay (aRVF, 15 [7-29] days; other indications, 13 [6-25] days; P = .042). Despite more complications, including nonsurgical bleeding (aRVF, 31%; other indications, 25%; P = .042) and persistent right-sided heart failure (aRVF, 50%; other indications, 17%; P < .001), both in-hospital survival (aRVF, 59%; other indications, 61%; P = .526) and long-term survival were comparable (log-rank P = .17). CONCLUSIONS:Patients requiring ECLS for post-cardiotomy aRVF, despite higher preoperative risks and complex clinical courses, achieve survival rates comparable to those of patients with other indications.

Background: Inconsistent reports exist regarding the efficacy of using a concomitant intra-aortic balloon pump (IABP) among cardiac arrest (CA) patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR). Thus, this review was conducted to summarize the prognoses of adult ECPR patients with concurrent IABP. Methods: Data were gathered from PubMed, Embase, MEDLINE, Web of Science, and Cochrane databases. Cohorts of adult patients receiving ECPR with or without IABP, reporting short-term mortality, neurological outcomes, or extracorporeal membrane oxygenation (ECMO) weaning rates, were recruited. Characteristics of the study population and the above-mentioned outcomes were extracted. A random-effects model was used to pool the data. Subgroup analyses were conducted in the propensity score-matching (PSM) population. Results: Nine cohorts with 5260 adult ECPR patients were included. In-hospital/30-day mortality, neurological performances of survivors, and ECMO weaning outcomes were not significantly different between populations with and without IABP. Nevertheless, younger patients with IABP showed an apparent improvement in in-hospital/30-day mortality. Similar findings were demonstrated in the analyses of PSM cohorts. High heterogeneity was present in the total cohort. Conclusions: In ECPR populations, concomitant IABP did not influence short-term survival, neurological, or ECMO weaning outcomes in the total cohort. However, IABP exhibited a survival benefit in the younger ECPR population. Further research in specific populations is warranted to validate and endorse our aggregated data. The PROSPERO Registration: CRD42024528761, Registration Link: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024528761.

BACKGROUND:Current risk stratification for veno-arterial extracorporeal membrane oxygenation relies on static assessments, ignoring dynamic cardiac evolution. We aimed to identify longitudinal echocardiographic trajectory phenotypes and evaluate their association with in-hospital mortality. METHODS:We analyzed 2034 adults receiving veno-arterial extracorporeal membrane oxygenation for cardiogenic shock from a multicenter registry. Latent class mixed models and probabilistic template-matching were applied to serial echocardiographic data (left ventricular ejection fraction, end-diastolic diameter, right ventricular parameters) to identify trajectory phenotypes. Associations with mortality were evaluated using multivariable Cox and Fine-Gray competing risk models. RESULTS:Four dynamic phenotypes were identified: Dyn-A ("Refractory Stagnation," 17.0%), featuring persistent systolic suppression and progressive dilation; Dyn-B ("Isolated LV Recovery," 14.9%); Dyn-C ("Biventricular Failure," 6.1%); and Dyn-D ("Gradual Recovery," 61.9%). Static baseline phenotyping failed to stratify survival. Conversely, dynamic phenotypes were independently associated with mortality. The high-risk Dyn-A phenotype exhibited significantly higher mortality compared with the Dyn-B profile (adjusted hazard ratio 1.71, 95% CI 1.35-2.16), remaining significant after adjusting for baseline illness severity. CONCLUSIONS:Dynamic echocardiographic trajectories identify distinct phenotypes reflecting divergent cardiac responses to veno-arterial extracorporeal membrane oxygenation, ranging from recovery to progressive maladaptation. Longitudinal monitoring provides essential prognostic utility beyond static admission assessments.

BACKGROUND:Despite the growing use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a rescue therapy for acute myocardial infarction (AMI), in-hospital mortality remains high. AMI-specific evidence on prediction timing, calibration, and performance across centers remains limited. OBJECTIVE:To develop and evaluate interpretable in-hospital mortality prediction models for VA-ECMO-supported AMI patients using multicenter data from the CSECLS registry. METHODS:We retrospectively analyzed 1,833 patients from 84 centers between 2016 and 2023. One center (center 188; n = 183) was reserved for held-out evaluation, and the remaining 1,650 patients from 83 centers formed the development cohort. Six candidate models were compared using two clinically distinct information windows. The W1 window included baseline and pre-ECMO variables, and the primary W2 window included baseline, pre-ECMO, and ECMO-establishment variables. Model development and selection used center-aware internal-external cross-validation (IECV) within the development cohort, followed by evaluation in the held-out center 188. The performance of the recommended model was assessed using discrimination, calibration, decision curve analysis, comparison with the partial SAVE score, and SHAP-based interpretability. RESULTS:CatBoost was recommended for the primary W2 window (pooled IECV AUROC, 0.650). In the held-out center 188, CatBoost achieved an AUROC of 0.834 (95% CI, 0.770-0.891) and a Brier score of 0.182 (95% CI, 0.154-0.209). In the secondary W1 analysis, random forest was selected and achieved an AUROC of 0.855 (95% CI, 0.794-0.912) in the same held-out center. Calibration analysis revealed systematic underestimation of baseline risk and conservative probability estimates, highlighting the need for context-specific recalibration. Decision curve analysis suggested potential clinical net benefit, and the model outperformed the partial SAVE score in the same external cohort. SHAP analysis identified invasive mechanical ventilation, norepinephrine dose, ECMO indication category, arterial pH, mean arterial pressure, and pre-ECMO lactate as the leading predictors. CONCLUSIONS:The CatBoost model for the designated primary W2 window provided an accurate and interpretable tool to support early risk assessment, shared decision-making, and precision management in high-risk cardiogenic shock populations. Local recalibration and further multicenter validation are required before clinical use.

OBJECTIVES:Venovenous extracorporeal membrane oxygenation (ECMO) represents a standard and well-accepted modality of treating patients with refractory respiratory failure. Nevertheless, some patients might develop refractory hypoxemia, hemodynamic compromise or end-organ perfusion requiring a change. This study analyzed characteristics and outcomes of patients requiring a change from venovenous to a different ECMO configuration. DESIGN:Multicenter, retrospective, observational analysis of the Extracorporeal Life Support Organization Registry (2010-2020) in adult patients (≥ 18 yr old) underwent venovenous ECMO as initial cannulation strategy. SETTING AND PATIENTS:Comparison of patients who remained on venovenous ECMO vs. those who underwent configuration conversion and multivariable analysis to assess variables associated with configuration change. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Among 28,888 eligible venovenous ECMO runs, 702 (2.4%) received a change from the original configuration, including 399 (56.8%) conversions to venoarterial and 303 (43.2%) to hybrid ECMO configurations. Variables associated with conversion included: pre-ECMO cardiac conditions, bridge to lung transplant as indication, use of milrinone, epinephrine, sildenafil, bicarbonate, and 24-hour Pa o2 value. Conversion occurred at a median of 56 hours (interquartile range, 11.5-210 hr) after ECMO initiation, with earlier conversion to hybrid configuration. Increased rates of cardiovascular, hemorrhagic, vascular, renal, metabolic, infective, and circuit-related complications were reported in converted patients. In-hospital mortality was higher in converted patients (60.8%) overall, and highest for venovenous to venoarterial patients (63.2%). CONCLUSIONS:The venovenous patients converted to other ECMO configurations were 2.4% and experienced higher complication and mortality rates. Variables associated with conversion highlight the importance of initial configuration selection and should be considered as part of the risk stratification framework when evaluating a patient for individualized ECMO support mode/configuration.

Weaning from venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients with cardiogenic shock remains a major challenge in intensive care practice. Previous studies have explored cytokines and chemokines as potential predictors of weaning outcomes, often using limited biomarker panels and relatively small cohorts. We therefore evaluated whether patterns of soluble circulating factors could predict successful ECMO weaning in patients with cardiogenic shock. Additional tools that provide complementary biological information may improve early risk stratification during the weaning process. In this retrospective cohort study, we analyzed 247 adult patients with cardiogenic shock who received VA-ECMO support. Patients were randomly allocated to a derivation cohort (70

Objectives: Data on outcomes of patients undergoing isolated coronary artery bypass grafting (isolated CABG) versus CABG and concomitant left heart valve (LHV-CABG) surgery are conflicting, especially in extracorporeal life support (ECLS) settings. We compared characteristics, in-hospital outcomes, and overall survival between patients undergoing isolated-CABG and concomitant LHV-CABG requiring postcardiotomy ECLS from a large multicenter study. Methods: This retrospective, multicenter (34 centers), observational study included adults requiring postcardiotomy ECLS between 2000 and 2020. Clinical characteristics and outcomes were compared between patients who underwent isolated CABG with those who underwent LHV-CABG. Association between type of surgery and in-hospital survival was investigated through mixed-Cox proportional hazards models. Results: This study included 639 patients comprising 58.8% (n = 376) isolated CABG and 41.1% (n = 263) LHV-CABG, including 46.7% (n = 123) aortic, 38.8% (n = 102) mitral, and 14.5% (n = 38) combined aortic-mitral valve procedures. The LHV-CABG patients were older (P = .001), more frequently experienced preoperative pulmonary artery hypertension (P < .001), and 6.5% (n = 17) had active endocarditis. They required longer cardiopulmonary bypass times (P < .001) and cardiac surgery reoperations (P = .002). In-hospital mortality was 54.8% (n = 206) and 63.1% (n = 166) in the isolated CABG and LHV-CABG groups (P = .036), respectively. Crude hazard ratio for in-hospital mortality in LHV-CABG was 1.28 (95% CI, 1.03-1.58, P = .023) and did not change after adjustments. The 5-year postdischarge survival probabilities were 71.1% (95% CI, 61.0-82.2) and 69.3% (95% CI, 57.7-83.2; P = .210) for isolated CABG and LHV-CABG groups, respectively. Conclusions: LHV-CABG surgery, compared with isolated CABG, was associated with higher in-hospital mortality in patients requiring ECLS, whereas no midterm postdischarge survival differences could be detected. Early identification of patients in need for ECLS following LHV-CABG may improve outcomes.

In this multicenter retrospective study (Chinese Society of Extracorporeal Life Support [CSECLS] registry), we evaluated early lactate trajectories in 1,465 adults with cardiogenic shock surviving greater than 24 hours on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Unsupervised k-means clustering of serial lactates (baseline, 4 hours, 24 hours) defined four metabolic phenotypes. The "Persistent High" phenotype (5.7%) exhibited refractory hyperlactatemia (median 24 hour lactate 17.0 mmol/L) and the highest in-hospital mortality (85.7% vs. 27.9% in the "Low Stable" group; p < 0.001). Notably, this persistent hyperlactatemia occurred despite comparable ECMO flow indices (2.8 vs. 2.6 L/min/m2) and preserved venous oxygen saturation (72.2% ≥ 50%). The "Persistent High" trajectory independently predicted mortality (adjusted hazard ratio [HR]: 6.36, 95% confidence interval [CI]: 4.83-8.36) and severe organ failure, with findings reproduced in an external validation cohort (MIMIC-IV, n = 136). In conclusion, persistent hyperlactatemia during VA-ECMO may reflect impaired systemic oxygen utilization rather than insufficient macrocirculatory flow. Early trajectory-based phenotyping helps identify a refractory state of flow-metabolism decoupling, signaling a high-risk subgroup where conventional flow escalation alone may be insufficient.

Background Off-pump coronary artery bypass grafting (OPCABG) can trigger a significant postoperative inflammatory response despite avoidance of cardiopulmonary bypass. Remimazolam, an ultra-short-acting benzodiazepine, has demonstrated anti-inflammatory properties in preclinical studies, while ciprofol, a novel propofol analogue, remains unclear in its immunomodulatory effects. This study aimed to compare the effects of remimazolam and ciprofol on postoperative inflammatory response and sedation quality in patients undergoing OPCABG. Methods This single-center retrospective cohort study included 80 patients who underwent elective OPCABG and received mechanical ventilation with either remimazolam-based (n = 40) or ciprofol-based (n = 40) sedation between January 2024 and December 2025. The primary outcome was serum levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) at 24 and 48 hours postoperatively. Secondary outcomes included proportion of patients achieving target sedation (RASS − 2 to 0), recovery time, mechanical ventilation duration, hemodynamic parameters, and adverse events. Results At 24 hours postoperatively, the remimazolam group had significantly lower IL-6 levels (79.32 ± 14.56 vs. 94.18 ± 17.35 pg/mL, p < 0.001) and TNF-α levels (3.82 ± 0.92 vs. 4.58 ± 1.08 pg/mL, p = 0.001) compared with the ciprofol group, and these differences persisted at 48 hours. After multivariable adjustment for age, APACHE II score, operative duration, and preoperative baseline inflammatory markers, remimazolam remained independently associated with lower IL-6 levels and lower TNF-α levels at 24 hours postoperatively. The proportion of patients achieving target sedation was comparable between the two groups (90.0% vs. 87.5%, P = 0.724). After adjustment for confounders, the remimazolam group demonstrated significantly shorter recovery time and shorter mechanical ventilation duration. The remimazolam group had a significantly lower risk of hypotension (adjusted OR = 0.33, 95% CI 0.12–0.89, p = 0.029) and reduced norepinephrine requirements (β=-0.04, 95% CI -0.07 to -0.01, p = 0.015). No significant differences were observed in the incidence of delirium, bradycardia, or other adverse events between the two groups. Conclusion Remimazolam provides comparable sedation efficacy to ciprofol in OPCABG patients while exhibiting superior anti-inflammatory effects, faster recovery, shorter mechanical ventilation duration, and better hemodynamic stability. These findings suggest that remimazolam may be a preferred sedative for sedation after OPCABG, particularly in patients at risk of excessive inflammation or with limited cardiac reserve.

BACKGROUND:Prognostic assessment in patients with severe pneumonia requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO) has traditionally relied on static baseline characteristics. Whether the early physiological trajectory and modifiable management strategies, specifically sedation depth, influence survival remains uncertain. METHODS:We conducted a multicenter retrospective cohort study. A total of 1484 adult patients with severe pneumonia supported by V-V ECMO were analyzed. Machine learning techniques were employed to objectively identify key predictors of in-hospital mortality among 341 candidate variables. The impact of early sedation strategy (Light vs. Deep) on survival and organ complications was assessed using multivariable logistic regression and propensity score matching (PSM). RESULTS:Machine learning analysis identified 24-h lactate level as the most important variable, outperforming baseline age and pH. An exploratory threshold of 4.15 mmol/L for 24-h lactate was identified; mortality risk increased substantially beyond this value. Regarding management, the Light Sedation strategy was associated with lower norepinephrine requirements and a reduced incidence of severe AKI requiring CRRT (29.4% vs. 42.9%, p < 0.001). In multivariable analysis adjusted for baseline severity and complications, Light Sedation remained associated with improved survival after adjustment (Adjusted OR 0.612, 95% CI 0.475-0.784, p < 0.001). This survival benefit was confirmed in the PSM cohort (OR 0.54, p < 0.001). CONCLUSIONS:In severe pneumonia patients supported with V-V ECMO, survival associated with the early trajectory of metabolic recovery. A light sedation strategy was consistently associated with improved survival and reduced organ dysfunction; however, causality cannot be established in this observational study, supporting further investigation of physiology-guided and dynamically reassessed sedation strategies in this high-risk population.

Ventricular septal rupture (VSR) is a rare but often fatal complication of acute myocardial infarction (AMI), with a high mortality largely driven by resultant cardiogenic shock. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides emergency circulatory support and may improve outcomes. We retrospectively analyzed the Extracorporeal Life Support Organization (ELSO) Registry to identify adults (≥18 years) with post-AMI VSR receiving preoperative VA-ECMO (2000-2025). Clinical characteristics were compared between survivors and nonsurvivors. The primary outcome was in-hospital survival. Among 370 patients, the median age was 66 years, 70% were male, and 66% were in cardiogenic shock at ECMO initiation. Inferior AMI occurred in 56%, and 56% had prior mechanical circulatory support. In-hospital mortality was 68%. Survivors were significantly younger (median 62 vs . 67 years) and had lower rates of pre-ECMO cardiac arrest (7% vs . 21%), tamponade (2% vs . 8%), and renal replacement therapy (21% vs . 37%). Survivors also experienced longer duration of ECMO support and hospital length of stay. While rescuing many patients in post-AMI VSR-related shock, mortality remains high. Identifying predictors of survival and optimizing perioperative management are essential to improve outcomes in this high-risk group.

Postcardiotomy extracorporeal membrane oxygenation (PC-ECMO) is a critical rescue therapy for pediatric patients with refractory circulatory failure following cardiac surgery. This study aimed to evaluate in-hospital mortality and identify potential risk factors for adverse outcomes in pediatric PC-ECMO patients, using data from the Chinese Society of Extracorporeal Life Support registry. We analyzed pediatric patients (< 18 years) who received PC-ECMO for circulatory support from December 2016 to April 2024. Surgical complexity was categorized using the Risk Adjustment in Congenital Heart Surgery-2 (RACHS-2) method. A total of 487 patients were included, with an overall in-hospital survival rate of 48.9%. Higher mortality was observed in neonates (61.4%) than in infants and children. Independent predictors of in-hospital mortality included RACHS-2 category 4-5 (odds ratio [OR]: 2.976, p < 0.001), aortic cross-clamp time greater than 90 minutes (OR: 1.931, p = 0.007), elevated lactate at 24 hours post-ECMO (OR: 1.221 per mmol/L, p < 0.001), and renal complications (OR: 3.135, p < 0.001). The combined model achieved an area under the curve of 0.737, outperforming the individual predictors. In-hospital mortality in pediatric patients receiving PC-ECMO remains high, and is strongly influenced by surgical complexity, aortic cross-clamp time, metabolic recovery, and renal function.