IntroductionOur aim was to evaluate the beating heart technique during frozen elephant trunk (FET) total arch replacement.MethodsBetween 03/2013 and 01/2023, 357 patients underwent FET total arch replacement in one aortic centre. Patient characteristics, intra- and postoperative data were compared between 290 patients (81%) undergoing FET repair during cardioplegic arrest and 67 patients (19%) operated on using the beating heart technique after propensity score matching.ResultsAfter propensity score matching there were no statistically significant differences in preoperative characteristics, the underlying pathology, and regarding arterial inflow-cannulation or concomitant cardiac procedures. Aortic cross-clamp (p = .042) and cerebral perfusion (p = .003) times were significantly shorter in the beating heart group. Postoperative cardiac biomarkers were lower, but the difference did not reach statistical significance. In-hospital mortality was numerically lower (1 [2%] vs 4 [7%], p = .346), and the incidence of postoperative renal replacement therapy was significantly lower (p = .027) in the beating heart group. Usage of the beating heart technique was not a significant variable in our logistic regression model for in-hospital mortality, while an acute aortic pathology was highly predictive for the outcome (p = .006, odds ratio: 3.319).ConclusionsThe beating heart technique has the potential to improve postoperative outcome following FET total arch replacement. The approach may be helpful for patients with reduced left ventricular function because of shorter aortic cross-clamp times.

Hereditary spherocytosis (HS) is a rare inherited haemolytic anaemia. This case report outlines a neonatal patient with presumed HS requiring cardiopulmonary bypass (CPB) and the whole blood exchange transfusion carried out in the immediate pre bypass setting to ensure a successful outcome.

Redo sternotomy and complex redo surgery to replace the ascending aorta and the aortic hemiarch in the presence of an aortocutaneous fistula presents a unique technical challenge to prevent exsanguination upon chest re-entry and organ (particularly cerebral) ischemia during circulatory arrest. Meticulous preoperative planning, peripheral cardiopulmonary bypass, moderate hypothermic circulatory arrest before chest re-entry, and apical left ventricular venting were the cornerstones of our successful surgical approach. Adjunctive selective unilateral antegrade cerebral perfusion extended the safe hypothermic circulatory arrest time, reducing neurological morbidity. We present a case of aortic rupture twoyears after aortic root abscess repair and aortic valve replacement, describing our approach for safe redo surgery while ensuring sufficient cerebral and body perfusion.

AimsTo evaluate the roles of intraoperative changes in plasma osmolarity and pump time as predictor factors on postoperative hemodynamic instability and mid-term clinical outcomes, in adults undergoing cardiovascular surgeries with cardiopulmonary bypass.MethodsThis observational study included 172 adults undergoing cardiovascular surgery with cardiopulmonary bypass. Intraoperative changes in calculated plasma osmolarity were calculated from biochemical analyses of venous blood samples. Outcomes included the requirement for vasoactive drugs 24 hours postoperatively and mortality at 2years. Multivariate logistic regression models adjusted for EuroSCORE II were used to analyze the data.ResultsBoth changes in calculated plasma osmolarity (OR = 1.78; 95% CI 1.18-2.27; p = .0074) and pump time (OR = 1.18; 95% CI 1.05-1.35; p = .0090) were independently associated with higher odds of requiring vasoactive drugs 24 hours postoperatively. At 2years, changes in calculated plasma osmolarity (OR = 1.99, 95% CI 1.15-3.42; p = .0114) were associated with the combined outcome of death, hospitalization, and/or repeat cardiovascular surgery, independently of pump time (OR = 1.01; 95% CI 0.98-1.03; p = .2340), but not to mortality alone.ConclusionsChanges in plasma osmolarity and pump time during cardiopulmonary bypass were associated with postoperative hemodynamic instability. Additionally, changes in plasma osmolarity were associated with adverse outcomes at 2years.

IntroductionWe sought to evaluate cerebral and somatic oximetry in an integrated tissue perfusion monitoring strategy.MethodThirty adult patients undergoing full-spectrum cardiac surgery with Minimal Invasive Extracorporeal Circulation (MiECC) were recruited. We simultaneously assessed the adequacy of tissue perfusion with near-infrared spectroscopy (NIRS) for cerebral and tissue oximetry, cerebral autoregulation monitoring (COx), sublingual microcirculation with video microscopy and real-time in-line metabolic monitoring during cardiopulmonary bypass. The primary endpoint of the study was to evaluate the diagnostic accuracy of NIRS cerebral desaturation in predicting a global perfusion-related adverse clinical event.ResultsCerebral oximetry showed the higher positive and negative predicting values (50% and 67%, respectively) in detecting a tissue perfusion-related adverse outcome. Somatic oximetry was related to higher values compared to cerebral (p < .001) and followed a different trend. ROC analysis calculated a cutoff value of 22 for right-sided cerebral desaturation and 32 for cumulative left- and right-sided desaturation as a sensitive predictor of hyperlactemia. Microcirculatory parameters were impaired after induction of anesthesia, while they were preserved during cardiopulmonary bypass.ConclusionsNIRS cerebral oximetry represents a useful tissue perfusion monitoring tool. An AUC cutoff value of 22 for a single hemisphere and 32 bilaterally correlate with hyperlactemia and may serve as alarm for prompt action.

Venopulmonary ECMO (VP ECMO) is an advanced support strategy for patients with severe respiratory failure and right ventricular (RV) dysfunction, providing pulmonary protection by oxygenating blood and unloading the RV. This case discusses a 57-year-old female with septic cardiomyopathy, refractory cardiogenic shock, and ARDS, who developed progressive respiratory deterioration despite conventional treatment. Due to patient instability, she was placed on VP ECMO (femoral venous drainage and pulmonary artery reinfusion), guided exclusively by transesophageal echocardiography (TEE). The use of TEE enabled successful pulmonary artery cannulation without the need for fluoroscopic guidance. Additionally, a flotation catheter was used to facilitate guidewire placement, improving procedural success in this emergent situation. After initiating ECMO, the patient showed significant clinical improvement, with resolution of RV dilation and paradoxical septal motion. This case underscores the feasibility and safety of TEE-guided VP ECMO, suggesting that the flotation catheter technique could be beneficial in critical situations, warranting further investigation to establish clinical guidelines.

Extracorporeal Membrane Oxygenation (ECMO) has evolved significantly over the decades, from its early experimental stages to its current use as a standard of care in intensive care medicine. ECMO devices continue to evolve rapidly. "Building on the past - a bridge to the future" emphasises balance: moving forward with a vision for the future, while drawing strength and guidance from what has come before. Understanding the past in the development of the ECMO device components such as oxygenators and pumps will guide future innovations, as will the lessons learned from complications such as clotting or the advances in anticoagulation management. The future development will bring significant improvements in portability, safety, efficiency, and accessibility of ECMO. Advances in AI-driven monitoring and predictive models, biocompatible materials, and expanded clinical applications will make ECMO a more effective and widespread tool for managing critical heart and lung failure. These innovations are likely to make ECMO available earlier, in more settings, and safer for a wider range of patients, ensuring that it continues to save lives in an increasingly diverse range of medical situations.

IntroductionThis article presents our experience with an alternative cannulation strategy for VV ECMO, adding it to previously reported cases found on PubMed.Case reportWe report three cases: two patients aged 17 and one aged 3. Two required VV ECMO for pneumonia, and one for airway surgery. All patients had a two-site approach. In two cases, drainage was initiated from the left side of the neck at the onset of therapy, with return to the groin. One patient required a change in the drainage cannula from the right to the left side during treatment, while the return continued to the groin.DiscussionMany centres have reported positive outcomes with alternative sites for cannulation in adults, including the left side of the neck. Alternative sites for cannulation require proper visualization techniques for guidewire and cannula insertion due to possible complications. We share our positive experience with left-sided cannulation using transthoracic echocardiographic visualization and a supraclavicular approach in paediatric patients of various weights.ConclusionLeft-sided cannulation is a safe option in specific clinical cases. Further studies are needed to validate this approach, especially for paediatric patients.

Neurological morbidity and mortality remain high in children requiring extracorporeal membrane oxygenation (ECMO). Although the severity of illness at the time of ECMO initiation and the nature of the underlying disease are strongly linked to the development of acute brain injury, several important factors are associated with neurological complications during ECMO support. Many of these factors, particularly those encountered during the early phase of ECMO initiation (first 24 hours), may be modifiable and represent potential targets for interventional studies aiming for improvement of neurological outcomes in pediatric ECMO patients. In this review from the European Extracorporeal Life Support Organization (EuroELSO) Working Group on Neurologic Monitoring and Outcome, we aim to summarize current knowledge on modifiable factors associated with brain injury during ECMO and their potential impact on outcome.