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.

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.

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

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: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.

BackgroundExtracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with severe respiratory and/or cardiac failure. In patients with severe pneumonia, severe septic shock led to the need for vasopressor and inotropic drugs to maintain the patients' circulatory function. The vasoactive inotropic score (VIS) is calculated as a weighted sum of all administered vasopressor and inotropic medications and quantifies the amount of pharmacological cardiovascular support. This study aimed to evaluate the association between preoperative VIS score and clinical outcomes among adult severe pneumonia patients with sepsis undergoing ECMO support.MethodsAdult patients diagnosed with severe pneumonia complicated with sepsis from January 2013 to June 2022 were obtained from the Chinese Society of Extracorporeal Life Support (CSECLS) registry database. The study endpoints included in-hospital mortality and failure of weaning for ECMO. Restricted cubic spline (RCS) was used to explore the association between VIS and the risk of adverse clinical outcomes. A backward stepwise logistic multivariable regression was used for assessing influence factors of study endpoints. Unadjusted and adjusted odds ratio (OR) and 95% confidence interval (CI) were calculated to identify the association.ResultsAmong 825 enrolled patients, there were 386 cases of in-hospital mortality and 241 cases of ECMO weaning failure. Patients in the in-hospital death group were older, had a higher SOFA score, lower mean arterial pressure, and higher VIS. A linear relationship existed between VIS and the risk of in-hospital death as well as the risk of failed weaning from ECMO support. Regardless of whether patients received VV-ECMO assistance or VA-ECMO support, as the VIS level increased, both the risk of in-hospital mortality and the risk of ECMO weaning failure also increased linearly. In the further subgroup analysis, the results were found to be robust.ConclusionLinear correlation existed between VIS score and the risk of in-hospital death as well as the risk of ECMO weaning failure in adult patients with severe pneumonia combined with sepsis. With the increase of VIS score, the risk of in-hospital death and ECMO weaning failure also increased. VIS may be a useful practical tool for risk stratification of adverse clinical outcomes.

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.

Post-extubation respiratory deterioration remains a concern in adult cardiac surgery patients requiring prolonged postoperative mechanical ventilation, even after a successful spontaneous breathing trial (SBT). We evaluated the association between pre-extubation lung ultrasound score (LUS) and escalation to non-invasive ventilation (NIV) within 48 h after extubation. This single-center prospective observational study included adult cardiac surgery patients who required invasive mechanical ventilation for > 24 h and successfully completed an SBT. LUS was assessed after the SBT and before extubation using a standardized 12-zone protocol, with a total score ranging from 0 to 36. The primary outcome was NIV escalation within 48 h after extubation. LUS was analyzed primarily as a continuous variable using logistic regression, and its discriminative performance was assessed using receiver operating characteristic (ROC) analysis. Prespecified LUS strata (< 11, 11–14, and > 14) were used for descriptive analyses. Among 120 patients, 32 (26.7

Background: This study aimed to evaluate the clinical efficacy of in-line mechanical insufflation–exsufflation (IL-MIE) in airway secretion management in patients receiving invasive mechanical ventilation after cardiopulmonary bypass (CPB). Methods: A total of 56 patients who underwent CPB and required invasive mechanical ventilation in the Cardiac Surgery Intensive Care Unit of Beijing Anzhen Hospital, Capital Medical University, between July 2015 and July 2020, were enrolled and divided into an IL-MIE group (n = 28) and a conventional suction (CS) group (n = 28). The IL-MIE group received automated secretion clearance every 30 min for 8 h, supplemented with CS as needed, whereas the CS group received standard CS treatment. General patient data, respiratory and hemodynamic parameters, ventilator settings, CS frequency, mechanical ventilation duration, and intensive care unit (ICU) length of stay were recorded during the 8 h intervention. Results: At 4 h and 8 h, the IL-MIE group exhibited significantly higher arterial oxygen partial pressure, oxygenation index, and static compliance and low plateau pressure (p < 0.05). Heart rate was significantly lower in the IL-MIE group at 4 h ((99.21 ± 13.87) vs. (89.32 ± 10.66); p < 0.01) and 8 h ((96.71 ± 14.47) vs. (89.61 ± 9.34); p = 0.033). The IL-MIE group required fewer CS interventions (0 (0, 1) vs. 4 (3, 4); p < 0.01) and had a shorter duration of mechanical ventilation (20 (16.75, 22) vs. 24 (18.75, 26.5); p = 0.029) than those in the CS group. Conclusions: By mimicking physiological airway clearance, IL-MIE significantly improves oxygenation and lung compliance, reduces the duration of mechanical ventilation, and maintains hemodynamic stability during respiratory management in patients after CPB.