Ventricular septal defect (VSD) is a mechanical complication of myocardial infarction that can lead to rapid multiorgan system failure. Mechanical circulatory support is an invaluable tool to stabilize these patients before definitive surgical repair. The Impella 5.5 has been successfully used to maximize end-organ perfusion and as a bridge to delayed surgical repair. Preserving this device intraoperatively at the time of VSD repair is of great importance as mishandling can lead to device damage, thrombosis, and various postoperative complications. In this paper, we discuss tips on how to preserve this device during VSD repair.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a key support modality for cardiogenic shock. The 2018 United Network for Organ Sharing (UNOS) heart transplant allocation algorithm prioritizes VA-ECMO patients.OBJECTIVE: To evaluate the role of VA-ECMO in bridging to advanced heart failure therapies.METHODS: We analyzed adult patients from the multicenter Extracorporeal Life Support Organization registry receiving VA-ECMO for cardiac support or resuscitation between 2016 and 2021 in the United States, comparing bridge-to-transplant (BTT) and non-BTT intent patients, as well as pre-vs post-2018 patients, on a wide range of demographic and clinical outcome predictors.RESULTS: Of 17,087 patients, 797 received left ventricular assist device (LVAD)/heart transplant, 7,931 died or had poor prognosis, and 8,359 had expected recovery at ECMO discontinuation. Patients sup-ported with BTT intent had lower clinical acuity than non-BTT candidates and were more likely to receive LVAD/transplant. The proportion of patients who received VA-ECMO as BTT and received LVAD/transplant increased after 2018. Post-2018 BTT patients had significantly lower clinical acuity and higher likelihood of transplant than both post-2018 non-BTT patients and pre-2018 BTT patients. ECMO complications were associated with lower likelihood of transplant but were significantly less common post-2018 than pre-2018.CONCLUSIONS: After implementation of the 2018 UNOS allocation system, ECMO utilization as BTT or LVAD has increased, and the acuity of BTT intent patients cannulated for ECMO has decreased. There has not yet been an increase in more acute ECMO patients getting transplanted. This may par-tially explain the post-transplant outcomes of ECMO patients in the current era reported in UNOS. J Heart Lung Transplant 2023;42:1059-1071 & COPY; 2023 International Society for Heart and Lung Transplantation. All rights reserved.