Only a small number of English hospitals provide postcardiotomy venoarterial extracorporeal membrane oxygenation (VA‐ECMO) and there are doubts about its efficacy and safety. The aim of this service evaluation was to determine local survival rates and report on patient demographics. This was a retrospective service evaluation of prospectively recorded routine clinical data from a tertiary cardiothoracic center in the United Kingdom offering services including cardiac and thoracic surgery, heart and lung transplantation, venovenous extracorporeal membrane oxygenation (VV‐ECMO) for respiratory failure, and all types of mechanical circulatory support. In six years, 39 patients were supported with VA‐ECMO for refractory postcardiotomy cardiogenic shock (PCCS). We analyzed survival data and looked for associations between survival rates and patient characteristics. The intervention was venoarterial‐ECMO in patients with PCCS either following weaning from cardiopulmonary bypass or following a trial of inotropes and intra‐aortic balloon counterpulsation on the intensive care unit. 30‐day, hospital discharge, 1‐year and 2‐year survivals were 51.3%, 41%, 37.5%, and 38.5%, respectively. The median (IQR [range]) duration of support was 6 (4‐9 [1‐35]) days. Nonsurvival was associated with advanced age, shorter intensive care length of stay, and the requirement for postoperative hemofiltration. Reasonable survival rates can be achieved in selected patients who may have been expected to have a worse mortality without VA‐ECMO. We suggest postoperative VA‐ECMO should be available to all patients undergoing cardiac surgery be it in their own center or through an established pathway to a specialist center.

Background: Severe acute pancreatitis is associated with sever multiorgan failure from 15 to 50%, depending on the series. In some of these patients, conventional methods of ventilation and respiratory support will fail, demanding the use of extracorporeal membrane oxygenation (ECMO). Abdominal compartment syndrome is potentially harmful in this cohort of patients. We describe the successful treatment of three patients with severe acute pancreatitis who underwent respiratory ECMO and where intra abdominal pressure was monitored regularly. Methods: Retrospective review of case notes. Results: Three patients with severe acute pancreatitis requiring ECMO suffered from increased intra abdominal pressure during their ICU stay. No surgical interventions were taken to relieve abdominal compartment syndrome. Survival to hospital discharge was 100% Conclusions: Monitoring intraabdominal pressure is a valuable adjunct to decision making while caring for these high-risk critically ill patients.

Postcardiotomy cardiogenic shock (PCCS) is a rare but catastrophic syndrome that can occur following separation from cardiopulmonary bypass or at any time during the immediate postoperative course. The management of PCCS varies between clinicians, institutions and countries. The available evidence to guide this practice is limited. In their systematic review and meta-analysis, Khorsandi and colleagues report a synthesis of case-series pertinent to the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for PCCS. Whilst we acknowledge the potential survival benefit for carefully selected patients for what is ordinarily a condition with high mortality, we wish to comment on several aspects of the study in the context of its application to clinical practice.Keywords: Postcardiotomy, VA-EMO, Systematic review, Cardiogenic shockIn their systematic review and meta-analysis of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for postcardiotomy cardiogenic shock (PCCS), Khorsandi and colleagues report a pooled survival to hospital discharge of 30.8% and suggest a number of adverse prognostic indicators [1]. Whilst we agree that postcardiotomy VA-ECMO for refractory cardiogenic shock does indeed provide a significant survival benefit, we wish to highlight several limitations so as to aid interpretation of this study and inform future analyses.With regards the search strategy, it was unclear from which database(s) (Medline and/or PubMed) articles were retrieved and from when the search extends. A recent Cochrane review advised against the pooling of studies from prior to 2000 due to significant advances in technology, yet three of the included studies are from the 1990s [2]. The use of other databases, a Google™ search and searching the bibliography of included manuscripts could have ensured a more comprehensive strategy. With regards inclusion and exclusion criteria, all transplant and non-transplant patients receiving VA-ECMO for postcardiotomy cardiogenic shock were included. At our institution, it is generally more common for VA-ECMO to be employed following heart transplantation than it is following non-transplant cardiac surgery. Anecdotally, we also find that outcomes following planned VA-ECMO use following heart transplantation are better as compared to unplanned non-transplant postcardiotomy VA-ECMO. Given that transplant and non-transplant patients have very different baseline characteristics together with different pre, intra and postoperative courses, it may have been advisable to statistically treat transplant and non-transplant groups separately to further reduce data heterogeneity. The finding that all studies were observational in design and with many employing retrospective data collection, is shared by our systematic review of extracorporeal life support for postcardiotomy cardiogenic shock [3]. We also found considerable difficulty in retrieving all relevant articles due to variable definitions of PCCS and extracorporeal life support (ECLS) in the literature.With regards ...

To our knowledge, this is the first study reporting the PK profile of ART drugs during ECMO therapy. Based on our results, dose adjustment of ART drugs while on VV ECMO may be advisable. Further study of the PK profile of Lamivudine is required.