ObjectivesCardiopulmonary bypass (CPB) impairs endothelial function, causing oedema and disturbed microcirculatory perfusion, that contribute to organ dysfunction following cardiac surgery. We hypothesised that the composition of CPB prime fluids with either albumin or gelofusine preserves sublingual microcirculatory perfusion in patients undergoing coronary artery bypass graft surgery.MethodsThirty-four patients were subjected to CPB primed with 1500ml of either albumin/ringers (n = 8, gelofusine/ringers (n = 11), or solely ringers plus retrograde autologous priming (RAP) (n = 15). All solutions included 100ml of mannitol. The primary outcome was perfused vessel density (PVD) assessed after anaesthesia induction, aortic cross-clamping, weaning from CPB, upon intensive care unit (ICU) arrival and 24h after ICU arrival.ResultsCPB immediately impaired PVD across all groups, persisting until ICU arrival. The decrease in PVD was most profound with albumin/ringers (estimated mean difference between baseline and ICU arrival -7.56 [95% CI -11.53 to -3.59] mm.mm-2), compared to gelofusine/ringers (-4.10 [-7.53 to -0.67] mm.mm-2), and ringers/RAP (-3.77 [-6.64 to -0.90] mm.mm-2), without differences between groups (p = 0.41). In patients receiving gelofusine/ringers COP was preserved after aortic cross clamping. Concentration of inflammatory (interleukin-6) and endothelial damage markers (angiopoietin-2) were increased with albumin/ringers compared with gelofusine/ringers and ringers plus RAP.ConclusionIn this exploratory physiological study, all of the three CPB priming strategies, albumin/ringers, gelofusine/ringers or ringers plus RAP, similarly induced perioperative microcirculatory dysfunction in patients undergoing CABG surgery.

Myxomas are considered the most common among primary tumors. But right atrial myxomas are relatively rare.[1] A 49 year old male presented with left upper and lower limb hemiparesis which recovered spontaneously without residual weakness within 24 h without thrombolysis. A known diabetic and hypertensive, he was thoroughly evaluated which revealed a multifocal right atrial myxoma attached to the right atrial free wall and extending into the superior venacava. Serum anti-cardiolipin antibody IgG was positive. The myxoma was promptly excised under general anaesthesia. Cardiopulmonary bypass was instituted with cannulation of the aorta, right femoral vein draining the inferior venacava (IVC) and high superior venacava (SVC) under transesophageal echocardiography guidance. The sieve like infiltrations into the SVC were excised by briefly decannulating the SVC followed by immediate recannulation. Myocardial protection was ensured with pulmonary artery venting, del Nido cardioplegia, sterile topical ice saline and terminal warm reperfusion. The patent foramen ovale was directly closed with prolene sutures. Right atrial myxomas are known to be associated with antiphospholipid antibody syndrome, thus making it mandatory to be ruled out.[2] Right atrial myxomas are rare and those associated with patent foramen ovale are a further rarity.[4] Our approach to the excision of the myxoma has been unique since the inferior venacava was drained with right femoral vein cannulation to prevent disrupting the mass and further embolism, pulmonary artery venting was done instead of left atrial venting to prevent manipulation of the mass during right atrial retraction and the resection of the mass infiltrating into the SVC wall was done carefully by briefly decannulating the SVC and immediately recannulating post resection.

Paradoxical coronary embolism (PCE) is an uncommon cause of acute myocardial infarction (AMI), typically occurring when venous thromboemboli cross a right-to-left shunt in the setting of elevated right-sided pressures. We report a case of mixed obstructive and cardiogenic shock caused by simultaneous pulmonary embolism (PE) and PCE. A previously healthy 43-year-old woman developed profound hypoxemia and inferior ST-segment elevation 3days after knee surgery. Coronary angiography revealed distal right coronary artery occlusion, successfully treated with aspiration thrombectomy and percutaneous coronary intervention. Persistent hypoxemia, right ventricular injury, and hemodynamic collapse prompted initiation of venoarterial extracorporeal membrane oxygenation (VA ECMO). Subsequent imaging identified extensive bilateral PE and a patent foramen ovale with significant right-to-left shunting. Catheter-based pulmonary embolectomy improved cardiopulmonary function, followed by percutaneous PFO closure. She recovered fully and was discharged home neurologically intact. This case highlights the importance of early recognition, appropriate ECMO configuration, and comprehensive management of PCE with concurrent PE.

BackgroundExtracorporeal Life Support (ECLS) services are characterised by variability in resource availability, specific expertise, device management and team organisation, especially regarding the role of perfusionists. This international survey aimed to investigate perfusionists' education, training and role within the ECLS team.MethodsThis is a descriptive, self-reporting, cross-sectional, voluntary, confidential international survey addressed to professionals involved in ECLS management, including perfusionists. The survey was distributed from April to August 2025 through congress, newsletter and social media platforms.ResultsA total of 178 ECLS centres submitted completed surveys. Most centres provided both cardiac and respiratory support (n = 153, 86%) for over 10years (n = 117, 65.2%). Perfusionists, mainly holding a bachelor's degree (n = 77, 47.5%), were reported to be responsible for ECLS device in 87.1% (n = 155) of centres, including priming (n = 156, 87.6%), setting management (n = 123, 69.1%), circuit/membrane lung replacement (n = 151, 84%) and running the emergency hand-crank (n = 133, 74.7%); though roles were often shared with multidisciplinary teams. Perfusionists were reported as part of retrievals/transports teams by 81.5% (n = 145) of responders. Education practices were reported as heterogeneous, with limited periodic ECLS-specific training programs (monthly: n = 19, 10.7%; every 6months: n = 48, 27%; yearly: n = 31, 17.4%; no continuous education provided: n = 55, 30.9%).ConclusionsThis international survey revealed marked variability in perfusionist education, training and roles within the ECLS teams, and related organization. Despite their technical responsibilities, a growing multidisciplinary collaboration is reshaping team dynamics. The absence of a standardized education remains a critical gap, requiring appropriate actions and planning by professional and scientific societies.

IntroductionPediatric extracorporeal membrane oxygenation (ECMO) is a highly complex therapy characterised by rapidly evolving physiology, high complication rates, and substantial cognitive demands on multidisciplinary teams. Management requires continuous integration of physiologic, laboratory, ventilatory, and circuit-derived data to support time-critical decisions related to gas exchange, haemodynamics, anticoagulation, transfusion, circuit surveillance, and weaning. Despite technological advances and growing international standardisation, morbidity and mortality continue to be driven by neurologic injury, bleeding and thrombosis, and clinical factors influencing successful liberation from ECMO support.AimTo review contemporary artificial intelligence (AI) and machine learning (ML) applications relevant to pediatric ECMO and evaluate their potential role as clinically aligned decision-support tools for clinicians and ECMO practice.MethodsA narrative review of English-language literature (2020-2026) was conducted using PubMed, MEDLINE, and Scopus to identify AI/ML studies, systematic reviews, and guideline documents addressing pediatric ECMO outcomes, complication prediction, circuit surveillance, and weaning or decannulation support, as well as methodological and governance frameworks relevant to clinical implementation.ResultsMost ECMO-AI applications employ supervised learning or deep learning approaches integrating demographic, clinical, laboratory, and ECMO device time-series data. Recent studies demonstrate emerging promise for neurologic risk prediction, bleeding and transfusion risk forecasting, circuit anomaly detection, and dynamic assessment of weaning readiness. Progress has included registry-based analyses, externally validated pediatric models, and time-series frameworks aligned with clinical workflows. However, heterogeneity in data quality, outcome definitions, and validation strategies remains substantial.ConclusionAI-guided tools in pediatric ECMO are transitioning from early feasibility studies toward more mature, clinically aligned decision-support applications. With rigorous validation, transparent reporting, and strong governance, AI has the potential to enhance situational awareness and consistency of care while preserving the central role of expert multidisciplinary judgement.

BackgroundThe bleeding in cardiac surgery remains a significant clinical problem. There is no "gold standard" method to quantify blood loss. Traditional measurement of drainage volume often underestimates or overestimates, as it does not consider the type of fluid. We hypothesized that blood loss could be more accurately calculated using the Hb/kg index in terms of haemoglobin (Hb) mass loss per kilogram of the patient's body mass. This study aimed to ObjectiveTo develop a novel approach for calculating actual blood loss using the Hb/kg index.MethodsThis single-center prospective study included 195 patients who underwent cardiac surgery between October 2023 and November 2024. The Hb/kg index was calculated based on intraoperative Hb loss, Hb loss via chest tubes, packed red blood cell transfusions and patient weight. Eighty-six additional clinical predictors were analyzed using conventional statistics and machine learning algorithms. Predictors with statistically significant Spearman correlations were included for further analysis.ResultsLasso regression achieved the best overall performance in predicting Hb/kg index. It yielded the lowest mean squared error (0.08 ± 0.04), mean absolute percentage error (0.18 ± 0.10), with the highest correlation (0.92 ± 0.06) and R² score (0.82 ± 0.13). BMI showed a significant negative relationship (-0.018, p < 0.001). Postoperative Hb and haematocrit values had negative correlation (-0.69, p < 0.001 and -0.07, p < 0.015), while initial Hb was positively correlated (0.85, p < 0.001).ConclusionsThis method provides a more reliable and clinically relevant tool to calculate actual blood loss and allows for a more precise assessment and treatment.

Venovenous extracorporeal membrane oxygenation (VV ECMO) is a potentially lifesaving yet resource-intensive organ support option for patients with very severe respiratory failure refractory to optimized conventional management. Mortality remains high, and ECMO is associated with significant complications, including bleeding, thrombosis, and vascular injury. Indication and timing of ECMO initiation are critical, as premature and also delayed use can affect outcomes. Current evidence, including findings from the CESAR and EOLIA trials and subsequent meta-analyses, supports the consideration of ECMO in very severe acute respiratory distress syndrome (ARDS) when lung-protective ventilation, prone positioning, and adjunctive therapies fail to ensure adequate gas exchange. Patient selection should rely on individualized risk-benefit assessment considering age, comorbidities, organ dysfunction, reversibility of lung injury, and patient-centered goals, rather than any single exclusion criterion. Management during ECMO focuses on ultra-protective ventilation to minimize ventilator-induced lung injury, early detection of complications, and tailored anticoagulation strategies, although optimal anticoagulation protocols remain undefined. When performed in experienced centres, prone positioning during ECMO is feasible and safe, but evidence for a survival benefit is inconclusive. Extracorporeal carbon dioxide removal (ECCO2R) may facilitate ultra-protective ventilation but lacks a proven mortality benefit. Therefore, its use is currently not recommended outside the setting of well-designed clinical trials. Weaning from ECMO should be structured and guided by physiological readiness while maintaining lung-protective ventilation. Optimal outcomes are achieved in high-expertise, multidisciplinary centres, with ongoing research needed to refine patient selection, ventilation strategies, and complication management. Overall, VV ECMO remains an essential tool in the management of severe respiratory failure, requiring careful balancing of risks, resources, and individualized clinical decision-making.

IntroductionThe HEART-UA (Healthcare Extracorporeal Assessment and Resource Tracking in Ukraine) survey represents the first nationwide evaluation of extracorporeal life support (ECLS) and renal replacement therapy (RRT) availability in Ukraine. The study aimed to systematically characterize national ECLS and RRT capacity, assess temporal changes before and during the conflict, and identify major operational limitations affecting access to extracorporeal organ support.MethodsA structured cross-sectional survey was conducted among Ukrainian hospitals providing ECLS and/or RRT. Data collection included institutional characteristics, ECMO device availability, case volumes in 2021 and 2023, staffing models, barriers to ECLS provision, and the availability of CRRT and intermittent hemodialysis. Responses were clustered at the institutional level, and duplicates were merged. Categorical variables were compared between the pre-war and wartime periods using Fisher's exact or chi-squared tests where appropriate.ResultsTwenty-two institutional responses were analyzed, including 15 ECLS centers, 16 CRRT centers, and 19 IHD-capable institutions. Geographical distribution showed regional clustering of ECLS resources. No statistically significant expansion in ECMO device availability or procedural volumes was observed between 2021 and 2023. The predominant barriers to ECLS provision included shortages of consumables (60%), insufficient trained personnel (53%), and inadequate numbers of ECMO devices (47%). CRRT availability was higher, but most centers reported major limitations due to shortages of consumable circuits, machine availability, and infrastructural instability. Humanitarian aid related to extracorporeal support was received by only 27% of institutions and was irregular, fragmented, and insufficient to meet national needs.ConclusionsThe HEART-UA survey demonstrates that Ukraine's capacity to provide extracorporeal organ support has remained critically constrained during the war. Device availability, trained personnel, and consumable supply chains are still major limiting factors. Although many centers continue to provide lifesaving ECLS, CRRT, and IHD despite extreme operational challenges, the overall system is highly dependent on inconsistent humanitarian aid.

A 58-year-old male wearing a wearable cardioverter defibrillator due to severe dilated cardiomyopathy with multi-vessel coronary disease presented a cardiac arrest (CA) with ventricular fibrillation refractory to conventional cardiopulmonary resuscitation (CPR). The decision was made to expand CPR to extracorporeal cardiopulmonary resuscitation (ECPR) using extracorporeal life support in the prehospital setting. ROSC was obtained after pump activation, and the patient was admitted to the intensive care unit, sedated and mechanically ventilated while under ECPR support. Despite an initial hemorrhagic shock due to mispositioning of the initial arterial canula requiring surgical repair, neurological evaluation was favorable and allowed for emergency heart transplantation candidacy. The patient was transplanted on day 7 after CA and discharged neurologically intact for rehabilitation on day 60. This case report shows how ECPR can be a bridge to definitive treatment if adequately integrated into an optimized out-of-hospital cardiac arrest chain of survival.

Objectives Cardiopulmonary bypass (CPB) is essential to cardiac surgery but is associated with organ injury from non-physiological perfusion. Goal-directed perfusion (GDP) has emerged as a physiology-based strategy to optimize intraoperative perfusion by targeting specific hemodynamic and metabolic parameters, particularly oxygen delivery (DO 2 ). This review critically appraises the evidence supporting GDP during CPB, emphasizing comparative strategies, clinical outcomes, and limitations. Methods A narrative review of the literature was conducted, incorporating evidence from randomized controlled trials, observational studies, meta-analyses, and international guidelines addressing perfusion strategies during CPB. This review included studies evaluating DO 2 -guided, pressure-guided, and oxygen-metabolic-indicator-guided approaches, focusing on target definitions, outcome measures, and patient populations. Results Randomized and observational studies have consistently demonstrated that maintaining adequate DO 2 levels during CPB is associated with a reduced incidence of cardiac surgery–associated acute kidney injury (CSA-AKI), leading to the guideline endorsement of DO 2 -guided perfusion. In contrast, evidence on neurological outcomes, length of stay, and mortality remains limited and inconsistent. Pressure-guided and venous-oxygen-saturation– or oxygen-metabolic-indicator–guided strategies provide complementary physiologic information but have not independently demonstrated superiority in randomized trials. Substantial heterogeneity has been reported in perfusion targets, outcome definitions, patient risk profiles, and potential trade-offs, including increased transfusion exposure and implementation complexity. Conclusions Current evidence supports DO 2 -guided perfusion as an effective strategy to reduce CSA-AKI during CPB, although its impact on broader clinical outcomes remains uncertain. Future studies should focus on individualized perfusion targets that account for patient-specific risk, metabolic demand, temperature, and autoregulatory capacity, rather than universal thresholds.