Extracorporeal cardiopulmonary resuscitation (ECPR) is the only therapy capable of rescuing patients from refractory cardiac arrest, but its effectiveness is critically dependent on time to reperfusion. The system proposed here, grounded in current physiologic and systems-level evidence, is designed to reliably achieve extracorporeal membrane oxygenation (ECMO) flow within approximately 45 min of collapse. This model emphasizes tightly organized, strike team-like ECPR units, parallel activation pathways, and predefined deployment and transport strategies independent of cannulation location. As ECPR systems evolve, integration of artificial intelligence-enabled dispatch and decision-support tools may further improve reliability, scalability, and equitable access to timely reperfusion.

Objectives:Lower limb ischemia after extracorporeal life support for refractory cardiac arrest may be prevented by effective distal perfusion catheter (DPC) placement. We describe the prevalence of cannulated lower limb ischemia, the DPC technique and its improvements over time, and the blood flow velocities by doppler ultrasound associated with ischemia. Methods:Retrospective single-centre study including patients ≥18 years-old receiving extracorporeal life support under cardiopulmonary resuscitation. Data is expressed as frequencies (percentages), compared using Fisher's exact test. Logistic regression evaluated technical improvements associated with absence of ischemia. Blood flow velocity cutoffs associated with ischemia were determined according to receiver operator characteristics curves. Results:We included 338 patients, 60[50-66] years-old. Survival to discharge was 24%.DPC was placed under ultrasound guidance using stiff wires: initial technique. This was improved resulting in the optimized technique by distal perfusion catheter heparin perfusion, using >12 cm-long sheaths, and using braided sheaths to avoid kinking. Cannulated lower limb ischemia occurred in 23/338 [6.8 %] in the overall population, in 10/77[13 %] with the initial technique and 13/261[5 %] with the optimized technique, p = 0.01. Braided sheaths were associated with absence of ischemia in multivariable analysis, odds ratio 0.18, 95 % confidence interval [0.045-0.65], p = 0.001. Blood flow velocity associated with ischemia was ≤17 cm/s in the mid-superficial femoral artery, and ≤12 cm/s in the more distal arteries. Conclusions:Using the optimized distal perfusion catheter technique, ischemia prevalence was 5 %. Braided catheters were associated with absence of lower limb ischemia. Blood flow velocity thresholds associated with cannulated lower limb ischemia were ≤17 cm/s.

Background: Extracorporeal cardiopulmonary resuscitation (eCPR) is increasingly being used for cardiac arrest refractory to conventional resuscitation. While data suggests the benefit of eCPR in select populations, there are scarce outcomes data for patients with in-hospital cardiac arrest (IHCA) compared to those with out-of-hospital cardiac arrest (OHCA). Research Question: Do outcomes of eCPR differ between IHCA and OHCA? Methods: Using the Nationwide Readmissions Database from 2016 to 2022, we analyzed in-hospital outcomes of adult patients who underwent eCPR for IHCA vs. OHCA using multivariable logistic regression and propensity score methods. The study cohort was identified using ICD-10 diagnostic and procedural codes. Results: Of 4,365 patients treated with eCPR for cardiac arrest, 3,252 (74.5%) had OHCA and 1,113 (25.5%) had IHCA. During the study period, the proportion of patients with OHCA receiving eCPR significantly increased (p-trend<0.001). Patients with IHCA were older (54 vs. 53 years), more often female (37.8% vs. 33.1%) with a higher comorbidity burden, and less likely to have shockable rhythm. In-hospital mortality was higher in patients with IHCA compared to OHCA (66.5% vs. 56.4%, p<0.001). The length of hospital stay was longer, and the cost of hospitalization was higher for patients with IHCA vs. OHCA. After adjustment for comorbidities, IHCA was associated with higher mortality based on regression (odds ratio [OR], 1.56; 95% CI [confidence interval], 1.23-1.98) and propensity score-matched (OR, 1.62; 95% CI, 1.25-2.10) analyses. IHCA was associated with less major bleeding (OR, 0.73; 95% CI, 0.55-0.98) and less anoxic brain injury (OR, 0.75; 95% CI, 0.60-0.95) but higher risk of sepsis (OR, 1.65; 95% CI, 1.29-2.10). Conclusion: In patients with cardiac arrest treated with eCPR, IHCA was associated with increased in-hospital mortality compared to OHCA. These findings suggest a need for further studies to guide patient selection in clinical practice for eCPR in IHCA.

Introduction: Preoperative 3-dimensional (3D) planning in transcatheter aortic valve replacement (TAVR) has improved outcomes and reduced adverse events. Moderate and even mild paravalvular leak (PVL) is an important predictor of adverse events. PVL remains a challenge for TAVR in bicuspid severe aortic valve stenosis (AS). Here, we investigate virtual reality (VR) simulated TAVR implants in bicuspid severe AS to predict PVL. Hypothesis: VR TAVR simulation may predict PVL in bicuspid severe AS and allow for improved valve selection before TAVR procedures. Methods: Patients with bicuspid severe AS treated with TAVR between 2014 and 2018 were included. The aortic root, ascending aorta, and left ventricular outflow tract were reconstructed based on pre-operative computed tomography. A 3D TAVR valve was then inserted into the reconstructed root in VR. The primary endpoint was the percent circumference of valve malapposition in VR (Elucis, Realize Medical) as compared to the severity of PVL on postprocedure echocardiography. Results: 12 patients were included in this study. The mean age was 69.2 years ± 17 and 41.7% were female. 75% received a 26mm Sapien 3 valve (Edwards Lifesciences) and 25% had a 29 mm Evolut R CoreValve (Medtronic) implanted. Among patients who had no or trivial PVL (n=9), 7 patients had no malapposition on VR and 2 patients had less than 5% malapposition. Both patients with mild PVL had 10% malapposition. The only patient with moderate PVL had 25% malapposition (table 1, figure 1). There was 100% agreement between the VR simulated implants and post-procedure PVL measured by echocardiography. Conclusion: TAVR implantation in VR may predict PVL in bicuspid severe AS.

INTRODUCTION:The haemodynamic effects veno-arterial extracorporeal membrane oxygenation (VA-ECMO) remain inadequately understood. We investigated invasive left ventricular (LV) haemodynamics in patients who underwent treatment with an intensive care strategy involving extracorporeal cardiopulmonary resuscitation (ECPR). METHODS:We conducted invasive haemodynamic assessments on 15 patients who underwent ECPR and achieved return of spontaneous circulation. Left ventricular end-diastolic pressure (LVEDP), ejection fraction (LVEF), end-diastolic volume (LVEDV), and stroke work (LVSW) were evaluated using simultaneous invasive left heart catheterization and 3D echocardiography. Paired comparisons between high and low VA-ECMO flow were performed. RESULTS:Invasive haemodynamic studies were performed in 15 patients aged 58 (43,65) years at 3.0 (2.0, 4.0) days after cannulation. Six patients survived the index hospitalization, and 9 expired during the index hospitalization. Among the total cohort, transitioning from the highest VA-ECMO flow (median 4.0 L/min) to the lowest VA-ECMO flow (median 2.0 L/min) led to increases in LVEDV from 85 (68,125) mL to 106 (70,153) mL (p = 0.005) and LVEDP from 14 (8,23) mmHg to 17 (12,30) mmHg (p = 0.001), respectively. Similarly, the LVSW increased from 2051 ± 1525 mL*mmHg at the highest level of VA-ECMO flow to 2627 ± 1559 at the lowest VA-ECMO flow (p = 0.01). CONCLUSION:High VA-ECMO flow significantly reduced LVEDP, LVEDV, and LVSW compared to low VA-ECMO flow.

Background The role of hypothermia in post-arrest neuroprotection is controversial. Animal studies suggest potential benefits with lower temperatures, but high-fidelity ECPR models evaluating temperatures below 30 °C are lacking. Objectives To determine whether rapid cooling to 24 °C initiated upon reperfusion reduces brain injury compared to 34 °C in a swine model of ECPR. Methods Twenty-four female pigs had electrically induced VF and mechanical CPR for 30 min. Animals were cannulated for VA-ECMO and cooled to either 34 °C for 4 h (n = 8), 24 °C for 1 h with rewarming to 34 °C over 3 h (n = 7), or 24 °C for 4 h without rewarming (n = 9). Cooling was initiated upon VA-ECMO reperfusion by circulating ice water through the oxygenator. Brain temperature and cerebral and systemic hemodynamics were continuously monitored. After four hours on VA-ECMO, brain tissue was obtained for examination. Results Target brain temperature was achieved within 30 min of reperfusion (p = 0.74). Carotid blood flow was higher in the 24 °C without rewarming group throughout the VA-ECMO period compared to 34 °C and 24 °C with rewarming (p < 0.001). Vasopressin requirement was higher in animals treated with 24 °C without rewarming (p = 0.07). Compared to 34 °C, animals treated with 24 °C with rewarming were less coagulopathic and had less immunohistochemistry-detected neurologic injury. There were no differences in global brain injury score. Conclusions Despite improvement in carotid blood flow and immunohistochemistry detected neurologic injury, reperfusion at 24 °C with or without rewarming did not reduce early global brain injury compared to 34 °C in a swine model of ECPR.

Background: Extracorporeal life support (ECLS) provides organ perfusion in refractory cardiac arrest but during the initiation of ECLS mean arterial pressure (MAP) and carotid flow may be suboptimal due to hypotension and/ or insufficient flow. We hypothesized that cardiopulmonary resuscitation (CPR) in addition to ECLS may increase carotid flow and MAP compared to ECLS alone. Methods: Observational pilot study comparing hemodynamic parameters before and after CPR cessation in pigs supported by ECLS for experimental refractory cardiac arrest. Pigs were anesthetized, ventricular fibrillation was induced for 3 min, automated CPR performed for 30 min, ECLS was initiated then CPR stopped. Variables averaged over 3 s were compared between the last 3 s of CPR + ECLS and 3, 6, 30 s, and 5 and 10 min of ECLS alone. Data are expressed as medians (25-75 interquartile range) and compared using paired samples Wilcoxon test. Results: Nine pigs were included, ECLS was initiated at 2.7 (2.3-2.8) L/min. MAP during CPR + ECLS was 56 (53.0-59.2) mmHg, versus 50(45-57)mmHg, 52(46-59)mmHg, 61(50-63)mmHg, 57 (54-66)mmHg, 54 (47-58) mmHg of ECLS alone, p = 0.50, 0.61, 0.70, 0.44, 0.73 respectively. Carotid flow was 113(78-119) ml/min during CPR + ECLS versus 99(79-110)ml/min, 100(81-110)ml/min, 96(60-122)ml/min, 118 (101-130)ml/min, 124 (110-141)ml/min, p = 0.41, 0.52, 0.73, 0.33, 0.20 respectively. When ECLS was initiated at lower flow, 1.5 L/ min (one pig), MAP decreased from 59 to 45 mmHg, and carotid flow from 78.2 to 32.5 ml/min after 3 s of ECLS alone. Conclusion: Stopping CPR after effective ECLS initiation does not decrease MAP or carotid flow. Future studies may evaluate augmenting low flow ECLS with CPR.

The aspects of extracorporeal cardiopulmonary resuscitation critical for reestablishing an organized rhythm and subsequent functional survival are unclear. This study characterizes the impact of reperfusion with extracorporeal membrane oxygenation (ECMO) and percutaneous coronary interventions (PCI) on achieving an organized rhythm in patients with refractory shockable out-of-hospital cardiac arrest (OHCA).Methods and Results Two hundred eighty-nine consecutive patients in refractory shockable OHCA were placed on ECMO followed by coronary angiogram (n=289) and PCI (n=165). Patients were grouped based on the extracorporeal cardiopulmonary resuscitation stage where a sustained organized rhythm was achieved. Survival outcomes were evaluated by using the Cerebral Performance Category. Logistic regression analysis was performed to determine the relationship between Cerebral Performance Category and timing of organized rhythm. Standard advanced cardiac life support before hospital arrival resulted in 148 of 289 (51%) patients attaining an organized rhythm while 87 of 289 (30%) achieved an organized rhythm post ECMO cannulation but before PCI, and 37 of 289 (13%) achieved an organized rhythm following PCI. Obstructive coronary artery disease was observed in 192 of 289 (66%) patients. A total of 144 of 192 (75%) patients with obstructive coronary artery disease converted to an organized rhythm before PCI and 37 of 192 (19%) following PCI. Cerebral Performance Category score 1 or 2 was significantly more likely in patients with cardiac arrest and obstructive coronary artery disease who achieved an organized rhythm before PCI (odds ratio [OR], 3.9 [95% CI, 1.2-12.0], P=0.024).Conclusions Most patients undergoing extracorporeal cardiopulmonary resuscitation for refractory OHCA due to shockable rhythms achieved an organized rhythm before PCI independent of coronary artery disease burden. Also, neurologically favorable survival was more prevalent in those attaining an organized rhythm before PCI.

BACKGROUND:Mortality of out-of-hospital cardiac arrest (OHCA) remains high. Extracorporeal cardiopulmonary resuscitation (ECPR) has revolutionized OHCA treatment, but our understanding of the ECPR responder's clinical profile is incomplete. Carotid artery stenosis (CAS) is a well-established cardiovascular disease risk factor. The impact of CAS on OHCA outcomes remains unelucidated. OBJECTIVE:To assess whether CAS burden affects the outcomes of OHCA patients treated with ECPR. METHODS:This study included patients with OHCA admitted for ECPR consideration, who had carotid ultrasonography performed. A numeric scale was applied to the plaque to create a CAS burden numeric scale. The primary outcome of the study was survival at discharge, compared among the different degrees of CAS. Neurologically intact survival and surrogate markers of neurologic injury were the secondary study endpoints. To assess the independent effect of CAS burden on survival to hospital discharge, we conducted a logistic regression analysis. RESULTS:Between 2019 and 2023, carotid ultrasonography was performed on 163 patients who were admitted for refractory OHCA. CAS burden was equally distributed between the right and left carotid arteries. Logistic regression analysis indicated that the CAS burden was significantly associated with both overall and neurologically intact survival at discharge (p = 0.004). A linear relationship between the CAS burden and neuron-specific and S-100 levels was identified. Patients with normal carotids were significantly less likely to have encephalopathy on electroencephalograms. CONCLUSION:CAS burden independently predicts the risk for worse survival and neurologic outcomes in patients suffering refractory OHCA who are treated with ECPR.

AIMS:This study explores the evolution of organ donation from patients treated with extracorporeal-cardiopulmonary-resuscitation (ECPR) for refractory out-of-hospital-cardiac-arrest (OHCA) and evaluates the public health benefits of a mature ECPR program. METHODS:This retrospective, single-center study included OHCA patients (2016-2023) who had mostly initial shockable rhythms and were treated with ECPR. Organ donation rates from non-survivors through these years were analyzed. The public health benefit of ECPR was determined by the ratio of the sum of survivors with Cerebral Performance Category 1-2 and non-survivors who donated at least 1 solid organ, to the total ECPR patients. Temporal trends were analyzed yearly using linear regression. RESULTS:Out of 419 ECPR patients presenting with refractory OHCA over the study period, 116 survived neurologically intact (27.7%). Among non-survivors (n = 303), families of 41 (13.5%) consented to organ donation (median age 51 years, 75.6% male) and organs from 38 patients were harvested, leading to 74 organ transplants to 73 recipients. The transplanted organs included 43 kidneys (58.1%), 27 livers (36.5%), 3 lungs (4%), and 1 heart (1.4%), averaging 2.4 ± 0.9 accepted organs/donor. The number of organ donors and successful transplants correlated positively with the years since the ECPR program's initiation (ptrend = 0.009, ptrend = 0.01). Overall, 189 patients (116 survivors, 73 organ recipients) benefited from ECPR, achieving organ-failure-free survival. The cumulative public health benefit of ECPR, considering the 116 survivors and 38 donors was 36.8%. CONCLUSION:The public health benefits of an established ECPR program extend beyond individual ECPR patient survival, forming a new, previously under-recognized source of transplant donors.

INTRODUCTION:Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive and debilitating disorder that results from incomplete resolution of vascular obstructions resulting in pulmonary hypertension. Surgical pulmonary thromboendarterectomy (PTE) is the treatment of choice for CTEPH. Unfortunately, many CTEPH patients are ineligible for PTE or do not have access to an expert surgical center. Medical therapy imparts important symptomatic and exercise benefits for CTEPH patients, but it does not extend survival. Balloon pulmonary angioplasty (BPA) is an emerging transcatheter approach that is both safe and efficacious. However, the potential synergy between upfront BPA and medical therapy treatment approaches in patients with inoperable CTEPH is unknown. Here, we evaluated how the combination of BPA and medical therapy compared to medical therapy alone in a newly established BPA program. METHODS:Twenty-one patients with inoperable or residual CTEPH were evaluated in this single-center observational study. Ten patients underwent upfront BPA and medical therapy while 11 patients were treated with medical therapy alone. Hemodynamic and echocardiographic assessments were performed at baseline and at least 1 month after completion of therapy. Continuous variables were compared using t-test or Mann-Whitney U-test. Categorical variables were analyzed with Chi squared and Fisher's exact test where appropriate. RESULTS:Combination therapy significantly reduced mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR), but medical therapy only significantly lowered PVR. Comprehensive echocardiographic analysis revealed a more robust reverse right ventricular (RV) remodeling effect and augmentation of RV function with combination therapy. At the end of study, the combination therapy group had lower mPAP and PVR and better RV function. Importantly, there were no significant adverse effects in patients treated with BPA. CONCLUSION:Combination therapy significantly improves hemodynamics and RV function in inoperable CTEPH while carrying an acceptable risk profile, even in a newly developed program. Further studies comparing upfront combination therapy to medical therapy with larger, long-term, and randomized approaches should be considered.

Transcatheter aortic valve replacement (TAVR) is the mainstay of treatment of inoperable and severe high‐risk aortic stenosis and is noninferior to surgical aortic valve replacement (SAVR) for low‐risk and intermediate‐risk patients as well. We aim to compare the valve size, area, and transaortic mean gradients in SAVR patients before and after the implementation of TAVR since being approved by the Food and Drug Administration in 2011.

Background: Paravalvular leak (PVL) is a frequent TAVR complication. Prospective identification of patients who are likely to develop PVL after TAVR would likely lead to improved outcomes. Prior studies have used geometric characteristics to predict the likelihood of PVL development, but prediction and quantification has not been done. One of the reasons is that it is difficult to predict the mechanical deformation of the native diseased aortic valve prior to implantation of the prosthetic valve, as existing calcifications likely contribute to the seal between the prosthetic valve and the aortic annulus. However, the relatively amount the native valve plays in preventing PVL is unknown. Methods: A retrospective chart review was conducted identifying patients with mild or greater PVL. One patient who had substantial PVL was identified and a 3D printed (pre-TAVR) aortic root was created. Balloon-expandable TAVR stent frames were implanted within the 3D printed root and a new model was created. Using this geometry, computational fluid dynamics (CFD) simulations were done to quantify PVL. The PVL flow path was iteratively decreased to simulate the space occupied by a crushed native aortic valve and PVL was quantified. Results: PVL was found to decrease as the space occupying the PVL area increased, demonstrating that the native aortic valve contributes to reducing regurgitation. CFD simulations demonstrated that within the patient analyzed, the native valve occupies between 3–40% of the PVL pathway. Conclusion: A priori techniques that predict the development of post TAVR PVL should account for the native diseased valve as our simulations demonstrate that it plays a role in reducing PVL.