Extracorporeal membrane oxygenation (ECMO) has become an increasingly vital intervention for patients with severe cardiac and respiratory failure, significantly improving short-term survival rates. However, there is growing recognition of the importance of long-term outcomes, including health-related quality of life (HRQoL), functional recovery, and psychological well-being. This narrative review synthesizes clinical studies, systematic reviews, and cohort analyses from the past 20 years using PubMed and Google Scholar, focusing on adult ECMO survivors.Studies consistently demonstrate that although many survivors achieve functional independence, a significant proportion experience persistent limitation. Common long-term sequelae include reduced physical capacity, depression, anxiety, cognitive impairment, and challenges in social reintegration such as returning into employment. Outcomes vary by ECMO modality: Veno venous (VV) ECMO survivors typically report better HRQoL than those receiving Veno arterial (VA) ECMO, although depression appears more prevalent among VV ECMO survivors. Significant complications including neurological injury, limb ischemia, and bleeding remain major contributors to morbidity, particularly in VA ECMO cohorts. The differences reflect variation in underlying disease and complication burden between the 2 modalities. Rehabilitation strategies emphasizing early physiotherapy, structured discharge planning, and comprehensive long-term follow-up are associated with improved functional and psychosocial outcomes. Despite rising survival, existing literature reveals considerable heterogeneity, a lack of standardized outcome measures, and limited prospective multicenter data. Future research should focus on innovations in ECMO circuit design, safer anticoagulation protocols, and the development of standardized rehabilitation pathways. Incorporating long-term functional, psychological, and social outcomes into ECMO care paradigms, is essential to move beyond survival towards meaningful recovery, ultimately optimizing quality of life for ECMO survivors.

Extracorporeal membrane oxygenation (ECMO) has become an increasingly vital intervention for patients with severe cardiac and respiratory failure, significantly improving short-term survival rates. However, there is growing recognition of the importance of long-term outcomes, including health-related quality of life (HRQoL), functional recovery, and psychological well-being. This narrative review synthesizes clinical studies, systematic reviews, and cohort analyses from the past 20 years using PubMed and Google Scholar, focusing on adult ECMO survivors.Studies consistently demonstrate that although many survivors achieve functional independence, a significant proportion experience persistent limitation. Common long-term sequelae include reduced physical capacity, depression, anxiety, cognitive impairment, and challenges in social reintegration such as returning into employment. Outcomes vary by ECMO modality: Veno venous (VV) ECMO survivors typically report better HRQoL than those receiving Veno arterial (VA) ECMO, although depression appears more prevalent among VV ECMO survivors. Significant complications including neurological injury, limb ischemia, and bleeding remain major contributors to morbidity, particularly in VA ECMO cohorts. The differences reflect variation in underlying disease and complication burden between the two modalities. Rehabilitation strategies emphasizing early physiotherapy, structured discharge planning, and comprehensive long-term follow-up are associated with improved functional and psychosocial outcomes. Despite rising survival, existing literature reveals considerable heterogeneity, a lack of standardized outcome measures, and limited prospective multicenter data. Future research should focus on innovations in ECMO circuit design, safer anticoagulation protocols, and the development of standardized rehabilitation pathways. Incorporating long-term functional, psychological, and social outcomes into ECMO care paradigms, is essential to move beyond survival towards meaningful recovery, ultimately optimizing quality of life for ECMO survivors.

Introduction: The global prevalence of morbid obesity is increasing, presenting challenges in cardiac surgery. Morbid obesity (body mass index ≥40 kg/m²) is associated with a high burden of cardiometabolic comorbidities and obesity-specific physiological alterations that increase perioperative risk and complicate surgical, anesthetic, and cardiopulmonary bypass management. As the number of obese patients presenting for cardiac surgery rises, a synthesis of current evidence and perioperative strategies is needed to optimize outcomes in this high-risk population. Methods: This narrative review identified relevant literature through targeted searches of PubMed and Google Scholar, supplemented by screening the reference lists of key articles. Search terms included combinations of “cardiac surgery,” “morbid obesity,” “obesity,” “cardiopulmonary bypass,” “anesthesia,” “perfusion,” “postoperative complications,” and “critical care.” Studies were mapped to perioperative domains, including anesthesia and respiratory management, surgical and wound related considerations, perfusion and cardiopulmonary bypass strategy, intensive care unit (ICU) outcomes, renal complications, atrial fibrillation, bleeding, thromboembolism, and mortality. The evidence base was predominantly observational and review based, with limited randomized evidence. Discussion: Obesity poses multifactorial challenges in cardiovascular surgery by altering cardiac morphology, hemodynamics, and perioperative outcomes. Associated comorbidities such as diabetes, obstructive sleep apnea, and pulmonary hypertension increase operative risk and complicate anesthetic and perfusion management. Obese patients demonstrate altered pharmacokinetics, reduced pulmonary compliance, and heightened inflammation, requiring individualized strategies. Available evidence suggests that lean body mass informed perfusion, selected off-pump CABG, and early extubation may reduce complications, although high quality randomized evidence remains limited. Conclusion: Cardiac surgery in morbidly obese patients requires a coordinated, physiology-driven perioperative strategy to address obesity-specific anatomical and functional challenges. Tailored anesthetic, perfusion, and surgical approaches, supported by close multidisciplinary collaboration, are central to optimizing outcomes. Further research is needed to refine perioperative protocols, improve risk stratification beyond BMI, and clarify long term cardiovascular outcomes following surgery in this population.

Background Anticoagulation practices during cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) are critical for the success of these procedures, yet there exists significant variation in these practices across different regions and among healthcare professionals and institutes. Methods An international survey was conducted targeting perfusionists and other healthcare professionals involved in CPB and ECMO procedures. The survey collected data on professional roles, geographic practice locations, heparin usage in prime solutions, initial and maintenance dosing, anticoagulation monitoring methods, and alternative anticoagulants for patients with Heparin-Induced Thrombocytopenia (HIT). Results Responses were received from professionals in over 20 countries, predominantly perfusionists. A majority of respondents use heparin in the prime solution for CPB, with typical initial doses ranging from 3,000 to 10,000 units. Heparin administration before initiating CPB typically varies between 300 to 400 Units/Kg whereas for ECMO, doses are generally lower. Monitoring of anticoagulation primarily employs Activated Clotting Time (ACT), with a notable number also using Thromboelastography (TEG). For HIT cases, Bivalirudin and Argatroban were the most cited alternatives. Conclusion The survey highlights a diversity of anticoagulation practices in CPB and ECMO across different regions, reflecting variations in clinical protocols, regional standards, and available resources. This diversity highlights the need for ongoing international dialogue and standardization efforts to optimize outcomes in patients who require these critical procedures.

Extracorporeal membrane oxygenation (ECMO) supports patients with severe refractory cardiac or respiratory failure but managing residual circuit blood after weaning lacks consensus. After decannulation, the oxygenator and circuit retain approximately 500-700 mL of blood, depending on tubing length, cannula size, and circuit configuration. Clinicians usually choose among direct reinfusion, cell-salvage processing, or disposal. Direct reinfusion maintains circulating red cell mass and may help avert allogeneic transfusion, especially in borderline cases, but carries the risk of reintroducing free hemoglobin, inflammatory mediators, microthrombi, and air emboli. Cell salvage offers an intermediary strategy by removing harmful elements through washing and centrifugation, but introduces delays in volume return, mechanical red cell damage, loss of platelets and clotting factors, and added cost. Discarding the blood eliminates reinfusion risks but increases reliance on banked blood, which poses risks such as immunomodulation, transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), and resource depletion. Modified CPD blood bags have shown promise for temporarily storing blood from ECMO or RRT circuits, particularly in neonatal and pediatric patients.Additionally, residual blood salvage during ECMO circuit changes, an often-overlooked opportunity for autologous transfusion, deserves greater emphasis. In the absence of standardized guidelines, current practice remains heterogeneous. We advocate prospective, multicenter trials comparing these strategies with endpoints including transfusion requirements, hemolysis and inflammation biomarkers, fluid balance, organ dysfunction scores, cost implications, and survival. Evidence-based protocols will enhance patient safety, reduce costs, and standardize ECMO care.

The evolution of extracorporeal membrane oxygenation (ECMO) has led to an increasing reliance on objective parameters to detect complications early and enhance patient safety. One such parameter is the transmembrane pressure gradient, more commonly referred to as delta P (ΔP), the difference between the inlet and outlet pressures of the oxygenator. This measure has increasingly been recognized as a critical early indicator of thrombus formation within the oxygenator during ECMO support. However, its interpretation remains complex and context-dependent, particularly because delta P values are significantly influenced by the design features of different ECMO circuits, including pump head geometry and oxygenator configuration.

Objective Reduced opiate use and improved pain relief is associated with improved recovery and a decrease in opiate dependency postoperatively. The use of multimodal analgesia and opiate sparing techniques including regional analgesia has been shown to enhance recovery after surgery although there is no established evidence post cardiac surgery 1,2 Design and method We retrospectively reviewed 80 patients who had cardiac surgery through a midline sternotomy. 40 patients had a parasternal block post cardiac surgery and compared them with 40 patients who did not receive the block. We also analyzed the use of other analgesics in these patients postoperatively and compared opiate consumption, duration of postop ventilation, pain scores and ICU stay. Results and conclusions Results: All patients received a single dose of long-acting opioid (morphine) and paracetamol at the end of the surgery. Average total post operative opioid (PCA fentanyl) usage in the patients who received a block was 898 micrograms, significantly lower than the group that did not receive a block, who averaged at 1375 micrograms. Improved pain control and better patient comfort was noted, as demonstrated by profoundly decreased demands on the PCA, early mobilization and reduced pain scores in the first 12 – 16 hours post extubation. We also observed a 25% reduction in the need and frequency of rescue opioid analgesia required. Regular IV / oral paracetamol and PRN NSAIDs were prescribed in ICU, no change was seen in this. Average extubation time after arrival to ICU was 2.2 hours, as compared to 3.5 hours in the patients who did not receive a block. There was also a 20% reduction in the patients who developed PONV and required regular anti-emetic therapy. No major difference was observed in the length of ICU stay or hospital discharge.Conclusions: Multi-modal analgesia, including regional analgesia in the form of a superficial intercostal parasternal plane block helps reduce post-sternotomy pain, post-operative opioid usage and post-operative nausea and vomiting, thus improving recovery in patients undergoing cardiac surgery.

OBJECTIVES:Oxygen delivery (DO2) is a pivotal factor in maintaining adequate tissue protection during cardiopulmonary bypass (CPB). Despite its clinical significance, there is currently no global consensus regarding standardized DO2 monitoring or threshold strategies during CPB. This study aimed to evaluate current global practices related to DO2 monitoring during CPB and to assess awareness, implementation, and perceived clinical benefits, particularly in reducing acute kidney injury. DESIGN:A cross-sectional international survey. SETTING:Cardiac surgery centers globally, with distribution through platforms including the South West Asia and Africa Chapter of the Extracorporeal Life Support Organization. PARTICIPANTS:A total of 120 respondents including perfusionists, anesthesiologists, and cardiac surgeons. INTERVENTIONS:Not applicable (survey-based observational study). MEASUREMENTS AND MAIN RESULTS:The survey revealed 73.9% of centers actively practiced goal-directed perfusion (GDP), with significantly higher adoption in high-volume centers (>500 cases/year) (82% v 65% in low-volume centers). Monitoring methods varied, with 48.7% of respondents using continuous devices and 37.8% using intermittent calculations. For target parameters, more than 80% of respondents maintained specific DO2 thresholds, whereas hemoglobin management most focused on 80 to 90 g/L (32.8%), and cardiac index typically ranged from 2.4 to 2.6 L/min/m2 (65%). Clinical benefits include reduced acute kidney injury incidence reported by 55% of GDP users, although implementation barriers persisted, particularly financial constraints (45%) and limited resources (38%), preventing a wider adoption of continuous monitoring in resource-limited settings. CONCLUSIONS:These findings reveal significant global variability and underuse of DO2 monitoring during CPB. Despite emerging evidence supporting the benefits of GDP strategies, widespread adoption remains limited. Cost and limited access to advanced monitoring in low-resource settings were considered the major barriers that prevented continuous monitoring of DO2 during CPB. These insights highlight an urgent need for international guidelines and standardization to optimize patient outcomes in cardiac surgery.

Extracorporeal Membrane Oxygenation (ECMO) is increasingly used in refractory cardiac and respiratory failure, yet the role of perfusionists remains narrowly defined. While traditionally viewed as technical operators, perfusionists possess advanced expertise that are essential across the continuum of care. Their exclusion from key clinical and academic roles represents a structural gap possibly with implications for safety and outcomes. This letter advocates for redefining perfusionists as clinical stakeholders, formally integrated into decision-making, quality improvement, and research initiatives. Their engagement can enhance ECMO practice across a multitude of areas. Recognizing perfusionists as integral members of the multidisciplinary team is essential to advancing outcomes, and meeting the demands of increasingly complex extracorporeal therapies.

Introduction: Type A aortic dissection (TAAD) management has markedly evolved in the last 20 years. However, the effect of patient demographics on TAAD presentation and outcomes has not been extensively studied worldwide. The aim of this study was therefore to investigate patient characteristics and their association with the perioperative parameters in a mixed population of the Gulf Cooperation Council (GCC) region. Methods: Consecutive patients presenting with TAAD (n=68) at a single centre between 2015 and 2021 were included. Seasonal variations in the occurrence of TAAD were described. Data on patient demographics, past medical history, presenting symptoms, operative techniques, postoperative complications, and in-hospital mortality were collected retrospectively and compared between patients with low (n=34) versus high (n=34) socioeconomic status (SES), and p<0.05 was considered statistically significant. Results: Of the 68 TAAD patients (mean age at presentation, 48.2 ± 15.6 years), 79.4% were male. Admissions for TAAD peaked in spring with 25 cases, contrasting with the lowest number of 12 events in summer (36.8 versus 17.6%; RR 2.1; p=0.03). A total of 75% of patients were non-GCC nationals, of whom 31.4% originated from Western Asia/Levant, 25.5% from Southeast Asia, and 23.5% from the Indian subcontinent. Compared with the high-SES group, patients with low SES were numerically more likely to present with syncope (17.6% versus 2.9%; p=0.1) and featured a notable trend toward requiring more complex aortic reconstruction (88.2% versus 67.6%; p=0.08). Additionally, the low-SES group had numerically more prolonged intensive care unit and hospital length of stay, and a lower rate of previously diagnosed connective tissue disease (0 versus 11.76%, p=0.1). However, the rate of postoperative complications and in-hospital mortality were comparable between the groups. Conclusion: In this study from the GCC region, a significantly younger age at presentation with TAAD compared to Western data was identified, with considerable seasonal variation in incidence. In addition, patients with low SES presenting with TAAD appear to have increased resource usage during hospitalisation.

Introduction : Heparin, a commonly used anticoagulant in cardiac surgery, binds to antithrombin III (ATIII) to prevent clot formation. However, heparin resistance (HR) can complicate surgical procedures, leading to increased thromboembolic risks and bleeding complications. Proper diagnosis and management of HR are essential for optimizing surgical outcomes. Methodology : Diagnosis of HR involves assessing activated clotting time (ACT) and HR assays. Management strategies were identified through a comprehensive review of the literature, including studies exploring heparin dosage adjustments, antithrombin supplementation, and alternative anticoagulants in cardiac surgery patients with HR. A thorough search of relevant studies on HR was conducted using multiple scholarly databases and relevant keywords, resulting in 59 studies that met the inclusion criteria. Discussion : HR occurs when patients do not respond adequately to heparin therapy, requiring higher doses or alternative anticoagulants. Mechanisms of HR include AT III deficiency, PF4 interference, and accelerated heparin clearance. Diagnosis involves assessing ACT and HR assays. HR in cardiac surgery can lead to thromboembolic events, increased bleeding, prolonged hospital stays, and elevated healthcare costs. Management strategies include adjusting heparin dosage, supplementing antithrombin levels, and considering alternative anticoagulants. Multidisciplinary management of HR involves collaboration among various specialities. Strategies include additional heparin doses, fresh frozen plasma (FFP) administration, and antithrombin concentrate supplementation. Emerging alternatives to heparin, such as direct thrombin inhibitors and nafamostat mesilate, are also being explored. Conclusion : Optimizing the management of HR is crucial for improving surgical outcomes and reducing complications in cardiac surgery patients. Multidisciplinary approaches and emerging anticoagulation strategies hold promise for addressing this challenge effectively.

Left ventricular free wall rupture (LVFWR) is a rare but serious complication following ST-elevation myocardial infarction (MI), occurring in a small fraction of patients. Left Ventricular Free Wall Rupture presents as three types: There are three types of Left Ventricular Free Wall Rupture: Type 1 with an abrupt tear and high mortality, Type 2 with a slower tear, and Type 3 with aneurysm perforation. Despite reperfusion therapies, LVFWR remains concerning due to increased mortality described from 75% to 90%. We present a case of LVFWR in a 64-year-old with a history of previous aortic valve surgery and heart failure, managed through left thoracotomy surgical repair. Our approach led to successful repair, emphasizing collaborative intraoperative strategies for improved outcomes in LVFWR cases.

Introduction: Perfusion safety in cardiac surgery is vital, and this survey explores perfusion practices, perspectives, and challenges related to it. Specifically, it examines the readiness of on-call and emergency operation rooms for perfusion-related procedures during urgent situations. The aim is to identify gaps and enhance perfusion safety protocols, ultimately improving patient care. Methods: This was a preliminary survey conducted as an initial exploration before committing to a comprehensive study. The sample size was primarily determined based on a one-month time frame. The survey collected data from 236 healthcare professionals, including cardiac surgeons, perfusionists, and anesthetists, using an online platform. Ethical considerations ensured participant anonymity and voluntary participation. The survey comprised multiple-choice and open-ended questions to gather quantitative and qualitative data. Results: The survey found that 53% preferred a dry circuit ready for emergencies, 19.9% preferred primed circuits, and 19.1% chose not to have a ready pump at all. Various reasons influenced these choices, including caseload variations, response times, historical practices, surgeon preferences, and backup perfusionist availability. Infection risk, concerns about error, and team dynamics were additional factors affecting circuit readiness. Conclusion: This survey sheds light on current perfusion practices and challenges, emphasizing the importance of standardized protocols in regards to readiness of on-call and emergency operation rooms. It provides valuable insights for advancing perfusion safety and patient care while contributing to the existing literature on the subject.

Background: The del Nido cardioplegia solution is a widely used method for myocardial protection in various settings. However, there is limited evidence of its effectiveness in adult cardiac surgery, and the baseline solution, Plasma Lyte A, is not readily available, leading to the use of alternative baseline solutions. This study aims to investigate the effectiveness of routine del Nido cardioplegia in adult cardiac surgery and the impact of different baseline solutions on myocardial protection and other perioperative outcomes. Methods: This study was a prospective, double-blind randomized parallel group clinical trial conducted at a single tertiary care hospital in Iran. A total of 187 adult patients were evaluated for eligibility, of which 120 met the inclusion criteria for elective isolated CABG surgery. The patients were randomly assigned to three groups, with each group consisting of 40 patients. The control group received a normal saline-based routine del Nido cardioplegia, Intervention Group A received Ringer lactate-based del Nido cardioplegia, and Intervention Group B received plain Ringer-based del Nido cardioplegia. The levels of Creatine Kinase-MB (CK-MB), Troponin T, Troponin I, and lactate were primarily assessed at four different times: after anesthesia induction (Baseline), 2 h, 12 h, and 24 h. Results: Preoperative demographic and clinical characteristics were the same among groups with insignificant differences (p > 0.05). There was no significant difference among groups based on CK-MB, Troponin T, Troponin I, and lactate levels (p = 0.078, 0.143, 0.311, and 0.129 respectively). However, there was a significant difference in the time effect of Troponin T and Lactate (p = 0.034, p = <0.001). Conclusion: Normal saline, Ringer lactate, and plain Ringer provide comparable myocardial protection in adult-isolated CABG surgery with modified del Nido cardioplegia. Larger studies are needed to identify the best alternative to Plasma Lyte A while maintaining del Nido cardioplegia as the control.

Background: Prolonged postoperative stay (POS) in patients undergoing CABG is associated with increased cost, inefficient utilization of resources, and poor quality of care (QOC). We aim to identify predictors of prolonged POS and evaluate the overtime impact of multidisciplinary team (MDT) QOC protocols on POS at a newly established tertiary care center. Methods: A total of 1168 consecutive patients undergoing isolated CABG between 2015-2022 were evaluated. POS was identified as prolonged (>6 days) and short (≤ 6 days). Short vs. prolonged stay groups were compared by appropriate testing methods. Predictors of prolonged POS were determined by multivariable logistic regression. Trends in prolonged POS were determined using Joinpoint Software to calculate the average annual percentage change (AAPC). Results: Overall, 44.3% (517/1168) of patients had prolonged POS. Patients in the prolonged POS group were older (59.1±10.5 vs. 56.3± 9.5, P<0.001), more likely females (16.6% vs. 9.7%, P<0.001), and had a higher burden of hypertension (88.1% vs. 81.9%, P=0.004), and diabetes (74.8% vs. 62.7%, P<0.001). The prolonged POS group featured worse ejection fraction, higher serum creatinine, and more frequently required preoperative intra-aortic balloon pump insertion (Table) . On multivariable logistic regression, age, female gender, NYHA class ≥II, history of diabetes, preoperative creatinine level, preoperative EF, and preoperative IABP placement were independent predictors of prolonged POS (Figure A) . Between 2015-2022, more QOC protocols were initiated, with a 67% relative reduction in the proportion of patients with prolonged POS (85.7% to 28.3%), with an AAPC of -12.8, 95% CI [-16.3, -9.2], P<0.001 (Figure B). Conclusion: Initiating MDT QOC protocols was associated with a reduction in POS among patients undergoing CABG. Identifying predictors of prolonged POS can help in timely planning of milestones aimed at eliminating unnecessary POS.