IntroductionPulmonary artery (PA) cannulation is emerging as a method for concurrent cardiac and respiratory failure, but limited data exists on how cannula positioning, particularly cannula tip angle, affects perfusion symmetry. Due to varying pulmonary bifurcation geometry between patients, ensuring even distribution of oxygen-saturated blood becomes critical. This computational fluid dynamics (CFD) study investigated the effects of cannula positioning and angles on oxygen delivery within the PA using 6 different configurations.MethodAn idealized PA geometry based on a CT scan was constructed including the 6 different cannula configurations: two straight (short and long) and four angled (5° and 10° toward either pulmonary branch). Simulations assumed laminar, steady-state flow at 6L/min total (50% ECMO contribution). Oxygen transport was modeled as a passive scalar with 75% saturation from the heart and 100% from the cannula. Perfusion symmetry was quantified using the absolute difference in mean oxygen saturation (ΔSaO2) and partial pressure (ΔpO2) between the right (RPA) and left pulmonary arteries (LPA).ResultsCannula positioning and angulation influences oxygen distribution within the PA. Straight-tipped cannulas favored LPA-sided flow due to the natural geometry of the pulmonary artery (ΔSaO2 = 12.9-15.1%). A 5° RPA directed angulation achieved the most symmetric distribution (ΔSaO2 = 9.2%, ΔpO2 = 14.2 mmHg), whereas greater or opposite angulations increased flow asymmetry.ConclusionMinor cannula tip angulation, specifically 5° deflection towards the RPA, enhances bilateral PA oxygenation without increasing ECMO flow, providing a simple yet effective strategy for optimizing pulmonary ECMO perfusion.

ObjectiveTo compare and evaluate, a new viscoelastic point-of-care device, the Quantra QPlus® parameters with conventional hemostasis tests and TEG-5000® parameters.Design, Material and MethodsThis prospective homocentric observational study took place between January and June 2024 at the main community site Hospital, Jolimont's Hospital on adult patients undergoing elective cardiac surgery using cardiopulmonary bypass (CPB). Paired perioperative citrated and EDTA blood samples were collected and sent directly to the laboratory for analysis. The blood was analyzed in one hand with TEG-5000® (K, MA and alpha angle) in cardiac operating room and afterwards, simultaneously with Quantra QPlus® (CTH, FCS, PCS), citrate platelet count with specific fluorescent agent (PLT-F) and standard haemostasis testing (PT/INR, aPTT, Clauss Fibrinogen).ResultsMethod comparison analysis shows that Quantra's Parameters PCS and FCS were well correlated with PLT-F and Fibrinogen while TEG-5000® parameter were less. FCS and Alpha Angle predicted a Clauss Fibrinogen <150mg/dL with an area under the curve (AUC) respectively of 0.899 (n = 66) and 0.815 (n = 54). PCS and MA predicted a Platelet count <150k/µL with an AUC of 0.793 (n = 62) and 0.807 (n = 54) respectively. CTH and K predicted an aPTT (actin FS on CS-5100) >29,0s with an AUC of 0.864 (n = 60) and 0.702 (n = 60) respectively.ConclusionStrong correlations were observed between quantra parameters FCS and PCS with Clauss Fibrinogen and Platelet count. While Performance from ROC curves for predicted thrombocytopenia <150k platelet/µL is similar with TEG-5000, they are better for predicted fibrinogen concentration and prolonged aPTT.

Introduction Patients who decline blood transfusion for religious or personal reasons present a unique challenge in cardiac surgery. We developed and validated a preoperative point-based tool to predict the likelihood of achieving transfusion-free success in open proximal thoracic aortic aneurysm repair.Methods We retrospectively analyzed 1074 patients who underwent open proximal thoracic aortic aneurysm repair at a single academic center from 2012 to 2023. A multivariable logistic regression model was developed using cross-validation to identify independent predictors of bloodless success. Model performance was evaluated using area under the curve (AUC), Brier score, and F-score. A point system was derived from weighted coefficients of significant preoperative variables.Results Multivariable analysis identified 8 factors (p < 0.05) associated with bloodless aneurysm repair for the point system: body surface area (BSA), hypertension, reoperation, heart failure, baseline hemoglobin, extent of repair, concomitant procedure, and degree of hypothermia. The model demonstrated good discrimination (AUC = 0.761), calibration (Brier score = 0.192), and balance (F-score = 0.758). BSA ≥1.9m2 and preoperative hemoglobin ≥13.1g/dL (+8 points each) had the greatest positive influence on likelihood of bloodless operation, while proximal + distal extension in repair (-8 points) had the greatest negative influence on likelihood of bloodless operation.Conclusions This novel point-based scoring tool estimates the probability of transfusion-free success using readily available preoperative factors. It may assist in counseling patients who refuse blood products, guiding perioperative planning, and prioritizing resource-intensive optimization strategies for those at highest risk.

We report a case of successful treatment for a severe acute pulmonary hypertension crisis in a patient with Eisenmenger syndrome (ES) associated with patent ductus arteriosus following trauma-related spine surgery, utilizing both veno-arterial (V-A) and veno-venous (V-V) ECMO. The patient's clinical course was complicated by right ventricular failure amid a pulmonary hypertensive crisis, necessitating V-A ECMO support. Persistent hypoxia, despite improved right heart function, warranted transition to V-V ECMO. This case demonstrates that peripheral V-A ECMO can be safely employed to decompress the right heart in the presence of a significant PDA shunt. Furthermore, weaning from ECMO in these patients requires a much higher hematocrit in order to compensate for the chronic hypoxia.

PurposeTo reduce and avoid the use of exogenous blood products for neonates and infants, our center limits the use of packed red blood cells and does not use fresh frozen plasma in our cardiopulmonary bypass (CPB) circuit primes. This practice has resulted in several bloodless neonatal open heart surgical procedures including the entire post operative hospital stays. This case report describes a patient with Hypoplastic Left Heart Syndrome who underwent the Norwood procedure without the use of exogenous blood products. No other report of a bloodless Norwood procedure could be found in the literature.MethodsMiniaturized cardiopulmonary bypass circuitry, including shortened arterial and venous lines, minimized modified ultrafiltration and cardioplegia circuits, low holdup volume vents and autologous bypass circuit priming, was used to preserve adequate oxygen carrying capacity at CPB initiation and during the entire surgical procedure.OutcomeNo exogenous blood products were administered to this patient during their entire hospitalization.

Venovenous extracorporeal membrane oxygenation (VV ECMO) has become an increasingly preferred modality for respiratory support in neonates and infants under 10kg, driven by a growing recognition of its neurological safety advantages over venoarterial (VA) ECMO. Historically, VV ECMO was limited in this population due to small vessel size, anatomical constraints, and technical challenges in achieving stable high-flow access. Recent advancements, including the development of the Crescent Right-Atrial (RA) dual-lumen cannula and increasing adoption of multisite cannulation strategies, have significantly expanded VV ECMO feasibility in neonates and small infants. Institutional experiences now support the safety and efficacy of VV ECMO in this vulnerable group when performed with skilled teams and advanced imaging guidance. This review synthesizes current evidence, highlights evolving cannulation techniques, and presents innovative solutions aimed at improving outcomes for infants and children under 10kg requiring VV ECMO.

Static cold storage (SCS) on ice has remained the gold standard preservation method for heart transplantation, and prolonged cold ischemia outside the typical 4-6 hour window is associated with an increased risk of primary graft dysfunction - a consequence attributed to ischemic damage and reperfusion injury. This, unfortunately limits the travel radius for donor heart procurement, a key factor that contributes to the overall shortage of donor organs. Recent research and clinical data have illustrated the validity of other preservation systems in preserving cardiac allografts, and many of these devices have shown promise in potentially prolonging the tolerated ischemic time beyond the accepted standard. Unfortunately, little is known regarding the biological basis of these preservation systems. In this review, we explore the existing knowledge of ischemic reperfusion injury as it relates to the donor heart. We also focus on characterizing the cellular and molecular mechanisms underlying existing donor heart preservation methods, including SCS, Paragonix' SherpaPak, TransMedics' Organ Care System, and XVIVO Heart Perfusion System, highlighting current limitations and areas for improvement. Furthermore, we describe the preclinical and clinical heart transplant outcomes related to Hypothermic Oxygenated Perfusate (HOPE) preservation.

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 500-700mL 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.

BackgroundThe anatomy and morphology of the aortic arch and its supra-aortic arteries can vary significantly among individual patients. This variability may have a particular relevance in cardiovascular procedures or interventions, and specifically during the use of mechanical circulatory support. This importance accounts for a specific influence on hemodynamics in veno-arterial extracorporeal membrane oxygenation (V-A ECMO) through an axillary/subclavian artery access. The related hemodynamic effects and interplay with native cardiac blood flow dynamics have been poorly investigated.MethodsTo assess the existing patterns of aortic arch and related supra-aortic artery morphology, thoracic computed tomography (CT) scans of patients undergoing pre-procedural (trans-catheter aortic valve or aortic or other cardiovascular surgery) assessment were investigated. All CT scans clearly showing the thoracic aorta in all its anatomical parts were selected and evaluated in terms of anatomical features (aortic arch type, position of the supra-aortic arteries along the aortic arch or ascending aorta, length and disposition of the ascendent aorta and aortic valve plane, and descending thoracic aorta). Aortic arch morphology was classified according to the Madhwal description,1 namely Type I, II, and III based on the exit point of the left subclavian artery along the aortic arch, with Type III configuration with all the three supra-aortic arteries departing leftwards the aortic arch peak, and Type I presenting the left subclavian artery departing from the peak of the aortic arch.ResultsThe CT scans of 1228 patients were analyzed and categorized. Overall, 70% (860 cases) of the aortic arch were Type III, 16.9% (208 cases) Type II, and 8.4% (103 cases) Type I. No difference was found between male and female patients. Type III aortic arch morphology presents a potentially unfavorable relationship due to a retrograde flow from the right axillary or subclavian artery, in case of such a V-A ECMO perfusion access, allegedly towards/against the aortic valve and left ventricular ejection. Type I and II aortic arch morphology showed patterns potentially more favorable from a mechanistic point of view, with an apparent more favorable anatomical disposition for a blood flow mainly directed towards the descending aorta.ConclusionsAortic arch and supra-aortic artery morphology vary markedly among patients. However, in this large patient population, the majority of aortic arch morphology was Type III which has a potentially unfavorable interaction between the native blood flow and V-A ECMO retrograde flow from the right axillary/subclavian artery compared to the left-sided access. Dedicated fluid-dynamic studies investigating the actual right or left axillary artery-generated retrograde flow direction and distribution along the ascending aorta, aortic arch and descending aorta deserves further investigation. Indeed, the interplay of blood flows generated by the left ventricle and that of V-A ECMO perfusion from right or left axillary/subclavian arteries and the consequence of this interplay on oxygen mixing, delivery and LV afterload, are warranted due to the increased use of such an approach.

IntroductionTremelimumab in combination with Durvalumab has recently been approved for the treatment of unresectable hepatocellular carcinoma (HCC). While immune checkpoint inhibitors (ICIs) have transformed cancer therapy, they are associated with rare but potentially fatal immune-related adverse events, including myocarditis.Case reportWe report a case of fulminant myocarditis in a 66-year-old female with advanced HCC, 38 days after initiating the Tremelimumab/Durvalumab STRIDE protocol. She presented with cardiogenic shock requiring V-A ECMO support. High-dose corticosteroid therapy resulted in full recovery of cardiac function.DiscussionICI-associated myocarditis has a reported prevalence of 1.14%, with a high rate of major adverse cardiac events. We reported a case of Tremelimumab/Durvalumab-associated myocarditis requiring mechanical circulatory support. Prompt recognition and immunosuppression were critical for recovery.ConclusionClinicians should maintain a high index of suspicion for myocarditis in patients on ICI therapy, as early intervention can be lifesaving.