Perioperative Complications and Outcomes of 12 Patients Bridged to Heart Transplantation by Extracorporeal Membrane Oxygenation

Perioperative Complications and Outcomes of 12 Patients Bridged to Heart Transplantation by Extracorporeal Membrane Oxygenation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perioperative Complications and Outcomes of 12 Patients Bridged to Heart Transplantation by Extracorporeal Membrane Oxygenation Xing Fang, Jueyue Yan, Zhipeng Xu, Jingchen Zhang, Tong Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4184890/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Cardiogenic shock (CS) is characterized by end-organ hypoperfusion resulting from low cardiac output. Venous-artery extracorporeal membrane oxygenation (VA-ECMO), is widely used in patients presenting with refractory cardiogenic shock. The decision to use VA-ECMO as a bridge to heart transplantation has become widely accepted as a short-term option. However, complications can develop within weeks, which makes it unsuitable for bridging to transplantation and even affects the prognosis. Methods： Data were collected from 12 patients who received extracorporeal membrane oxygenation (ECMO) as a bridge to heart transplantation between October 2020 and October 2021. General perioperative characteristics, ECMO-related complications, and posttransplantation survival were summarized. Results： The 12 patients were male, with an average age of 45.33 years and an average BMI of 22.87 kg/m2. The main primary diseases were myocardial infarction (7 cases), dilated cardiomyopathy (4 cases), and fulminant myocarditis (1 case); the average ECMO maintenance time before transplantation was 14.25 days, the longest preoperative maintenance time was 37 days, the overall ECMO perioperative survival rate was 75.00%, and the 30-day survival rate was 91.67%. The main complications in the perioperative period are gastrointestinal bleeding, distal limb ischemia of the perfusion tube and distal limb ischemia requiring fasciotomy during ECMO maintenance, bleeding after transplantation in the operative area requiring reoperation for bleeding, and poor healing at the ECMO cannulation insertion site. Conclusion： ECMO as a bridge to heart transplantation is a feasible treatment option for patients with end-stage heart failure and refractory cardiogenic shock. We should be aware of the complications related to ECMO management. heart transplantation extracorporeal circulation support ECMO complications outcomes Figures Figure 1 1 Introduction Heart failure is a clinical disease with high morbidity and high mortality rates and is associated with repeated hospitalizations ( 1 – 4 ). Acute heart failure is associated with a rapid worsening of clinical symptoms and signs ( 5 , 6 ), including new-onset heart disease and acute exacerbations of chronic heart failure. Cardiogenic shock is the most serious clinical manifestation of acute heart failure, which is characterized by severe circulatory failure and is accompanied by hypotension and organ hypoperfusion in addition to a high mortality rate ( 7 ). Patients with cardiogenic shock should be identified and treated as soon as possible. In addition, mechanical circulatory support (MCS) effectively improves organ perfusion in patients with refractory cardiogenic shock ( 7 ). Among them, VA-ECMO plays an important role in end-organ perfusion support in patients with cardiogenic shock. In addition to cardiopulmonary function support, VA-ECMO can improve systemic organ perfusion ( 8 ) and is considered to be organ function support for refractory cardiogenic shock patients in the ICU transitioning to rehabilitation, those with a ventricular assist device or who have undergone heart transplantation, etc., which can be used to assess outcomes ( 9 , 10 ). There have been case reports on the use of VA-ECMO as a bridge to heart transplantation worldwide ( 11 ), but there are few descriptions of the perioperative maintenance process. In this article, we describe the patients who received VA-ECMO as a bridge to heart transplantation in our hospital in the previous year and discuss the impact of VA-ECMO as a bridge to heart transplantation on perioperative complications. 2 Materials and Methods Patient selection: A total of 12 patients who received VA-ECMO as a bridge to heart transplantation in the critical care unit of a tertiary medical center between 2020 and 2021 were retrospectively analyzed (Fig. 1 ). The general conditions of the 12 patients who received ECMO as a bridge to transplantation and the clinical complications and outcomes in the transplantation patients during the perioperative period were summarized. ECLS procedure: Cannulas were placed percutaneously by vessel puncture, guidewire placement, and serial dilation (Seldinger technique), and access was permitted via femoral vessels, which will be described in detail in the Results section. A 16- to 18-Fr arterial cannula and 21- to 24-Fr venous cannula were used depending on the patient’s blood vessel diameter. Distal perfusion cannulas (DPC) were routinely placed because of the poor distal artery flow after peripherally placed cannulas. A Swan-Ganz catheter was inserted to measure the pulmonary vascular resistance index (PVRI) before the operation, and SvO2 greater than 70% of the internal jugular vein was maintained during ECLS. The ECLS system was implanted under full heparinization, and heparin titration was performed with bedside measurement of activated partial thromboplastin time (aPTT, target value 1.5 to 2.5 times normal) every 4 h ( 12 ). Postcardiac transplantation management and antirejection medical therapy were based on the 2010 guidelines for the care of heart transplantation recipients ( 13 ). Definition 1. Refractory cardiogenic shock: Shock and organ insufficiency caused by low cardiac output despite optimal drug support ( 14 ). Perioperative definition: the period from VA-ECMO maintenance to the time when patients were discharged from the ICU and can receive rehabilitation after heart transplantation. Discharged from ICU standard: No organ function support is required (blood pressure is stable without vasoactive drugs, and the patient has ventilator independence, stable kidney and liver functions, with no potential infection) Discharged from cardiac surgery: the concentration of tacrolimus (FK-506) in the blood was stable; the wound healed well; there was no potential risk of infection; and regular outpatient follow-up was achieved. 3 Results As shown in Table 1 , all 12 patients were male, with an average age of 45.33 years and an average BMI of 22.87 kg/m2. The primary diseases distributed among the patients were myocardial infarction (7 cases), and all of the myocardial infarction patients underwent coronary artery angiography (CAG), which showed 3-vessel coronary artery disease (CAD), and the culprit vessel was reperfused; dilated cardiomyopathy (4 cases); and myocarditis (1 case). The average ECMO maintenance time before transplantation was 14.25 days, and the longest preoperative maintenance time was 37 days. The left ventricular ejection fraction (LVEF) was measured using the biplanar Simpson technique, and the LVEF ranged from 12–32%, with an average LVEF of 23.4%. Among them, 2 patients were treated with intra-aortic balloon pumps (IABP) combined with VA-ECMO as a bridge to heart transplantation. Allograft heart transplantation was successfully performed in all 12 patients, and the average aortic cross-clamp time in the operation was 57.5 min. Nine patients survived, 3 patients died, and the overall survival rate was 75.00%. Among them, Patient 3 was considered to have primary graft failure and ultimately died of multiple organ failure on the 7th day after transplantation; Patient 7 died of a bloodstream infection and septic shock on the 67th day after the operation; and Patient 9 had a mediastinum infection and suddenly died from an ascending aorta rupture (intraoperatively, the incision was 0.5 cm above the anastomosis, and the mediastinal infection eroded the blood vessels). The total perioperative ECMO survival rate was 75.00%, and the 30-day survival rate was 91.67%. Table 1 Patient characteristics. Primary disease sex age BMI(kg/m2) Demographics and comorbidity Previous CAG Patient 1 myocardial infarction Male 45 22.03 smoking 3-vessel CAD Patient 2 fulminant myocarditis Male 57 27.04 smoking CAG negative Patient 3 dilated cardiomyopathy Male 37 21.71 CAG negative Patient 4 myocardial infarction Male 37 23.67 smoking 3-vessel CAD Patient 5 myocardial infarction Male 59 21.25 diabetes 3-vessel CAD Patient 6 myocardial infarction Male 45 21.22 smoking 3-vessel CAD Patient 7 myocardial infarction Male 35 27.68 diabetes 3-vessel CAD Patient 8 dilated cardiomyopathy Male 46 27.78 CAG negative Patient 9 dilated cardiomyopathy Male 59 20.76 CAG negative Patient 10 dilated cardiomyopathy Male 28 18.36 CAG negative Patient 11 myocardial infarction Male 65 22.49 diabetes 3-vessel CAD Patient 12 myocardial infarction Male 31 20.41 3-vessel CAD Table 1 (continued) ECMO mode Catheter Site Catheter size DPC size Preoperative ECMO maintenance time ECMO + IABP Left ventricular unloading Venous cannula (femoral vein) Artery cannula (femoral artery) Venous cannula Artery cannula Patient 1 V-A ECMO Left side Right side 24Fr 18Fr 8.5Fr 2 days No Newly diagnosed HF Patient 2 V-A ECMO Right side Left side 21Fr 15Fr 8Fr 14 days No preoperation Newly diagnosed HF Patient 3 V-A ECMO Right side Left side 20Fr 16Fr 8Fr 6 days No Known chronic HF Patient 4 V-A ECMO Right side Left side 24Fr 18Fr 8.5Fr 37 days Yes Newly diagnosed HF Patient 5 V-A ECMO Right side Right side 22Fr 16Fr 8Fr 26 days No Newly diagnosed HF Patient 6 V-A ECMO Left side Left side 24Fr 16Fr 8Fr 24 days No Newly diagnosed HF Patient 7 V-A ECMO Right side Left side 22Fr 15Fr 8Fr 4 days Yes Newly diagnosed HF Patient 8 V-AV ECMO Right side Left side 22Fr 16Fr 8Fr 11 days No preoperation Known chronic HF Patient 9 V-A ECMO Right side Right side 22Fr 16Fr 8Fr 21 days No Already on the waiting list Patient 10 V-A ECMO Left side Right side 21Fr 16Fr 8Fr 3 days No Already on the waiting list Patient 11 V-AV ECMO Left side Right side 22Fr 16Fr 8Fr 15 days No Newly diagnosed HF Patient12 V-A ECMO Right side Right side 24Fr 18Fr 8Fr 8 days No Newly diagnosed HF Table 1. (continued) Preoperative Intubation time Preoperative Renal replacement EF Calculated By echocardiography PVRI（wood unit） Intraoperative aortic cross-clamp time (minutes) Patient 1 6 days 28% 3 67 min Patient 2 14 days yes 15% 4.3 72 min Patient 3 6 days yes 20% 3.8 52 min Patient 4 51 days yes 21% 2.7 48 min Patient 5 26 days yes 28% 3.5 65 min Patient 6 24 days yes 27% 3.2 43 min Patient 7 11 days yes 12% 4.8 56 min Patient 8 11 days yes 24% 4.2 67 min Patient 9 30 days yes 20% 4.5 66 min Patient 10 3 days yes 26% 5.5 49 min Patient 11 15 days yes 28% 4.4 51 min Patient 12 12 days yes 32% 3.8 54 min HF=Heart Failure; DPC= distal perfusion cannulas Among the 12 patients who underwent VA-ECMO bridged to heart transplantation (Table 2 ), the femoral vessels were the preferred access points in the patients, and different catheter sizes were selected according to the target vessels’ diameters, as were the DPC catheters. Lower extremity ischemia (LEI) occurred in 3 patients, and 1 of the 3 patients with LEI even required lower extremity fasciotomy (LEF). Except for the ECMO cannulation site, the bleeding manifestations we observed were mainly related to gastrointestinal bleeding, and 4 patients had postoperative bleeding requiring reoperation, but postoperative bleeding did not appear to be necessarily associated with patient outcomes. In addition to monitoring, ECMO-related complications mainly manifested as poor healing at the cannulation insertion site (5 cases). Average total length of ICU stay: 52.25 days. It seemed that poor healing at the insertion site was not related to catheter size or comorbidity. Table 2 Perioperative ECMO-related complications and outcomes in patients bridged to transplantation. Complications ICU-stay length Outcomes predischarge echocardiographic data LVEF (%) TAPSE (mm) Patient 1 LEI + LEF 52 days Discharge 62 15 Patient 2 Gastrointestinal bleeding 38 days Discharge 65 13 Patient 3 / 14 days Died Died because of PGD, CS, result in MOF at 7 days post-HT Patient 4 LEI 79 days Discharge 55 13 Patient 5 Reoperation for bleeding 105 days Discharge 60 14 Patient 6 Insertion site poor healing + Gastrointestinal bleeding + Reoperation for bleeding 61 days Discharge 69 17 Patient 7 LEI + Insertion site poor healing 67 days Died Died of a blood infection after pressure ulcer debridement Patient 8 Insertion site poor healing 27 days Discharge 66 14 Patient 9 Insertion site poor healing + Gastrointestinal bleeding + Reoperation for bleeding 70 days Died Died of an ascending aorta rupture after mediastinum infection Patient 10 Reoperation for bleeding 27 days Discharge 55 12 Patient 11 Insertion site poor healing 49 days Discharge 68 16 Patient 12 Gastrointestinal bleeding 38 days Discharge 65 15 (LEI = lower extremity ischemia; LEF = lower extremity fasciotomy; PGD = primary graft dysfunction; CS = cardiogenic shock; MOF = multiple organ failure) Before the patients were discharged, echocardiography was used to assess LVEF and tricuspid annular plane systolic excursion (TAPSE), and the average LVEF was 62.78% and TAPSE was 14.3 mm. 4 Discussion In the past few decades, VA-ECMO has been increasingly developed and applied and is widely used in clinical practice. Its function of supporting clinical hemodynamics and assisting gas exchange is important for clinical diagnosis, treatment, and organ recovery. VA-ECMO increases survival and has great benefits ( 15 , 16 ). At present, VA-ECMO has become an important rescue measure for critically ill patients, especially those with refractory cardiogenic shock who are transitioning to recovery or have undergone transplantation ( 16 ). In this paper, 12 patients whose heart function could not be recovered after VA-ECMO could not be weaned from ECMO and were directly bridged to heart transplantation, and we found that the postoperative survival rate was 75.00%. It has been reported in the literature that the survival rate in patients receiving short-term VA-ECMO as a bridge to heart transplantation can reach 50% ( 10 ), and the prognosis is not significantly different from survival after heart transplantation in common recipients ( 17 – 19 ). In their series, the 1-year survival rate of 13 patients who received ECMO support after transplantation (1 with postoperative shock, 8 with cardiomyopathy, and 4 with acute myocardial infarction) as a bridge to transplantation was 51%. However, the duration of ECMO support before transplantation has not been described. Our data focused on the peri-operative time in those patients, and none of them died before undergoing heart transplantation, which was an amazing result compared to that of Poptsov’s study ( 20 ), despite having a much smaller sample of patients. In addition, the 30-day survival rate was 91.67%, which was higher than previously reported values. The average maintenance time of preoperative ECMO support in our case series was 14.25 days. There have been reports in the literature suggesting that during the bridging process, the maintenance time of VA-ECMO ranges from 7 to 14 days. However, the longest maintenance time in our patients was 37 days, which is longer than that reported in previous studies ( 20 – 23 ). The main perioperative ECMO-related complications in 12 patients bridged to transplant included gastrointestinal bleeding, limb ischemia with or without fasciotomy, bleeding after transplantation in the operative area that requires reoperation to stop the bleeding, and poor healing around the puncture wound after ECMO was removed, which was common after weaning from ECMO support, and it has been reported that these complications might affect the outcomes ( 24 ). However, in our case series, we did not find a relationship between the complications. Therefore, due to the small sample size, it remains unclear whether perioperative complications are associated with the outcome. In conclusion, as the utilization of temporary MCS devices, including IABP, percutaneous ventricular assist devices (pVADs) and ECMO, has become increasingly common, the proportion of patients bridged directly to heart transplantation has exponentially increased. Compared to other MCS devices, ECMO provides a more stable flow for CS patients and is widely used in patients with unstable cardiac electrical activity ( 25 ). Although we did not have any experience with other MCS devices bridged to heart transplantation, the outcomes in patients with ECMO were satisfactory. VA-ECMO should be regarded as a bridge to emergency heart transplantation. However, ECMO-related complications are also our focus. Declarations Ethics approval and consent to participate This study have been performed in accordance with the Declaration of Helsinki, and was approved by the Medical Research Ethics committee of the First Affiliated Hospital, Zhejiang University School of Medicine. Written informed consent was obtained from all individual participants or from the legal representative (i.e., spouse or first-degree relatives) if the participants deceased. Consent for publication Not applicable. Availability of data and materials The datasets generated during and analyzed during the current study are not publicly available due to the privacy of individuals that participated in the study but are available from the corresponding author on reasonable request. Competing interest None of the authors declare competing interests. Funding This study is not funded by any grant. Authors' contributions Dr. Xing Fang , Dr. Jueyan Yan and Dr. Tong Li wrote the main manuscript text and Dr. Zhipeng Xu and Dr. Jingchen Zhang prepared figures and tables. All authors reviewed the manuscript. Acknowledgements Not applicable. References Conrad N, Judge A, Tran J, Mohseni H, Hedgecott D, Crespillo AP, et al. 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Advanced heart failure: a position statement of the heart failure association of the European society of cardiology. Eur J Heart Fail. 2018;20:1505–35. 10.1002/ejhf.1236 . Dunlay SM, Roger VL, Killian JM, Weston SA, Schulte PJ, Subramaniam AV, et al. Advanced heart failure epidemiology and outcomes: a population-based study. JACC Heart Fail. 2021;9:722–32. 10.1016/j.jchf.2021.05.009 . McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42:3599–726. 10.1093/eurheartj/ehab368 . Fuhrman BP, Hernan LJ, Rotta AT, Heard CM, Rosenkranz ER. Pathophysiology of cardiac extracorporeal membrane oxygenation. Artif Organs. 1999;23:966–9. 10.1046/j.1525-1594.1999.06484.x . Sertic F, Chavez L, Diagne D, Richards T, Wald J, Acker M et al. Predictors of in-hospital mortality and midterm outcomes of patients successfully weaned from venoarterial extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg (2021) 161:666 – 78.e3. 10.1016/j.jtcvs.2019.11.106 . Rousse N, Juthier F, Pinçon C, Hysi I, Banfi C, Robin E, et al. ECMO as a bridge to decision: recovery, VAD, or heart transplantation? Int J Cardiol. 2015;187:620–7. 10.1016/j.ijcard.2015.03.283 . Liao X, Cheng Z, Wang L, Li B, Huang W, Ye H, et al. Extracorporeal membrane oxygenation in patients with heart transplantation: a clinical prognosis analysis. Herz. 2020;45:739–44. 10.1007/s00059-019-04843-9 . McMichael ABV, Ryerson LM, Ratano D, Fan E, Faraoni D, Annich GM. 2021 ELSO adult and pediatric anticoagulation guidelines. ASAIO J. 2022;68:303–10. 10.1097/mat.0000000000001652 . Costanzo MR, Dipchand A, Starling R, Anderson A, Chan M, Desai S, et al. The international society of heart and lung transplantation guidelines for the care of heart transplant recipients. J Heart Lung Transpl. 2010;29:914–56. 10.1016/j.healun.2010.05.034 . Levy B, Bastien O, Karim B, Cariou A, Chouihed T, Combes A, et al. Experts' recommendations for the management of adult patients with cardiogenic shock. Ann Intensive Care. 2015;5:52. 10.1186/s13613-015-0052-1 . Basir MB, Schreiber T, Dixon S, Alaswad K, Patel K, Almany S, et al. Feasibility of early mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock: the detroit cardiogenic shock initiative. Catheter Cardiovasc Interv. 2018;91454–61. 10.1002/ccd.27427 . Ostadal P, Rokyta R, Kruger A, Vondrakova D, Janotka M, Smíd O, et al. Extra corporeal membrane oxygenation in the therapy of cardiogenic shock (ECMO-CS): rationale and design of the multicenter randomized trial. Eur J Heart Fail. 2017;19 Suppl 2124–7. 10.1002/ejhf.857 . Tran BG, De La Cruz K, Grant S, Meltzer J, Benharash P, Dave R, et al. Temporary venoarterial extracorporeal membrane oxygenation: ten-year experience at a cardiac transplant center. J Intensive Care Med. 2018;33:288–95. 10.1177/0885066616654451 . Fukuhara S, Takeda K, Kurlansky PA, Naka Y, Takayama H. Extracorporeal membrane oxygenation as a direct bridge to heart transplantation in adults. J Thorac Cardiovasc Surg. 2018;155:1607–e186. 10.1016/j.jtcvs.2017.10.152 . Barth E, Durand M, Heylbroeck C, Rossi-Blancher M, Boignard A, Vanzetto G, et al. Extracorporeal life support as a bridge to high-urgency heart transplantation. Clin Transpl. 2012;26:484–8. 10.1111/j.1399-0012.2011.01525.x . Poptsov V, Spirina E, Dogonasheva A, Zolotova E. Five years' experience with a peripheral veno-arterial ECMO for mechanical bridge to heart transplantation. J Thorac Dis. 2019;11:S889–901. 10.21037/jtd.2019.02.55 . Chung JC, Tsai PR, Chou NK, Chi NH, Wang SS, Ko WJ. Extracorporeal membrane oxygenation bridge to adult heart transplantation. Clin Transplant (2010) 24:375 – 80. 10.1111/j.1399-0012.2009.01084.x . Mishra V, Fiane AE, Winsnes BA, Geiran O, Sørensen G, Hagen TP, et al. Cardiac replacement therapies: outcomes and costs for heart transplantation versus circulatory assist. Scand Cardiovasc J. 2017;51:1–7. 10.1080/14017431.2016.1196826 . Carter KT, O'Brien R, Larson SB, Creswell LL, Kutcher M, Baran DA, et al. Venoarterial extracorporeal membrane oxygenation is a viable option as a bridge to heart transplant. J Thorac Cardiovasc Surg. 2022;163:140–e74. 10.1016/j.jtcvs.2020.08.026 . Lan C, Tsai PR, Chen YS, Ko WJ. Prognostic factors for adult patients receiving extracorporeal membrane oxygenation as mechanical circulatory support–a 14-year experience at a medical center. Artif Organs. 2010;34:E59–64. 10.1111/j.1525-1594.2009.00909.x . Zhou AL, Etchill EW, Giuliano KA, Shou BL, Sharma K, Choi CW, et al. Bridge to transplantation from mechanical circulatory support: a narrative review. J Thorac Dis. 2021;13:6911–23. 10.21037/jtd-21-832 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4184890","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288777162,"identity":"c571deb1-8351-4c29-b7fb-8225e3abcd31","order_by":0,"name":"Xing Fang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA70lEQVRIie3RMYoCMRSA4RcCSZMDBBZ3r5BhQC3EvUqGBT2AzVSaQYiNbC8Ke4U5QgYLGw/gdplmbCws7TRaWcXYCeYvH+8jCQGIxV4wqtDsKHP++UUVCDdA6hFhBmuw226azE0woRrVOs/UTt4GAYRn2sotR8Vib0cMeq3S4MZ6Catmwr0F0w8pUwaDtDSkI3zkmxaKu1MIWkrjyDorDSPcewpGyt2NM/ivlCPnAEILfSUcdhgcMQGEVVPhLiaS+QCSlfhJF2vS9hM+rOtTPp780U0jDnm/9buZNl5yHxG3z8Sh+9dd+8RyLBaLvVEX7/1JGFETfGMAAAAASUVORK5CYII=","orcid":"","institution":"The First Affiliated Hospital of Zhejiang University","correspondingAuthor":true,"prefix":"","firstName":"Xing","middleName":"","lastName":"Fang","suffix":""},{"id":288777163,"identity":"c7c4dd10-5b95-459a-8259-4ce2d2da8950","order_by":1,"name":"Jueyue Yan","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Jueyue","middleName":"","lastName":"Yan","suffix":""},{"id":288777164,"identity":"4e0b249a-b6e5-4e7c-ab59-d9d3a2beef65","order_by":2,"name":"Zhipeng Xu","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Zhipeng","middleName":"","lastName":"Xu","suffix":""},{"id":288777165,"identity":"49fcef10-5ff5-49b7-88fa-362b412fdb9e","order_by":3,"name":"Jingchen Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Jingchen","middleName":"","lastName":"Zhang","suffix":""},{"id":288777166,"identity":"2626b0df-d2db-4561-8d9a-984a7ff7cecf","order_by":4,"name":"Tong Li","email":"","orcid":"","institution":"The First Affiliated Hospital of Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Tong","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-03-29 00:59:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4184890/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4184890/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54372720,"identity":"d708b856-b2a0-425b-abfd-f9bc47f73cd3","added_by":"auto","created_at":"2024-04-09 13:24:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":125450,"visible":true,"origin":"","legend":"\u003cp\u003eTwelve patients who received VA-ECMO as a bridge to heart transplantation in the critical care unit of a tertiary medical center between 2020 and 2021.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4184890/v1/c940a319a9d49cdf15590c62.png"},{"id":58466000,"identity":"74516d77-4563-460f-b6f0-b525f117e6ba","added_by":"auto","created_at":"2024-06-17 04:14:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":728655,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4184890/v1/f21a4091-676d-477e-a8e0-5378e10642ab.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative Complications and Outcomes of 12 Patients Bridged to Heart Transplantation by Extracorporeal Membrane Oxygenation","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eHeart failure is a clinical disease with high morbidity and high mortality rates and is associated with repeated hospitalizations (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Acute heart failure is associated with a rapid worsening of clinical symptoms and signs (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), including new-onset heart disease and acute exacerbations of chronic heart failure. Cardiogenic shock is the most serious clinical manifestation of acute heart failure, which is characterized by severe circulatory failure and is accompanied by hypotension and organ hypoperfusion in addition to a high mortality rate (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Patients with cardiogenic shock should be identified and treated as soon as possible. In addition, mechanical circulatory support (MCS) effectively improves organ perfusion in patients with refractory cardiogenic shock (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Among them, VA-ECMO plays an important role in end-organ perfusion support in patients with cardiogenic shock. In addition to cardiopulmonary function support, VA-ECMO can improve systemic organ perfusion (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) and is considered to be organ function support for refractory cardiogenic shock patients in the ICU transitioning to rehabilitation, those with a ventricular assist device or who have undergone heart transplantation, etc., which can be used to assess outcomes (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). There have been case reports on the use of VA-ECMO as a bridge to heart transplantation worldwide (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), but there are few descriptions of the perioperative maintenance process. In this article, we describe the patients who received VA-ECMO as a bridge to heart transplantation in our hospital in the previous year and discuss the impact of VA-ECMO as a bridge to heart transplantation on perioperative complications.\u003c/p\u003e"},{"header":"2 Materials and Methods","content":"\u003cp\u003ePatient selection: A total of 12 patients who received VA-ECMO as a bridge to heart transplantation in the critical care unit of a tertiary medical center between 2020 and 2021 were retrospectively analyzed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The general conditions of the 12 patients who received ECMO as a bridge to transplantation and the clinical complications and outcomes in the transplantation patients during the perioperative period were summarized.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eECLS procedure: Cannulas were placed percutaneously by vessel puncture, guidewire placement, and serial dilation (Seldinger technique), and access was permitted via femoral vessels, which will be described in detail in the \u003cspan refid=\"Sec3\" class=\"InternalRef\"\u003eResults\u003c/span\u003e section. A 16- to 18-Fr arterial cannula and 21- to 24-Fr venous cannula were used depending on the patient\u0026rsquo;s blood vessel diameter. Distal perfusion cannulas (DPC) were routinely placed because of the poor distal artery flow after peripherally placed cannulas. A Swan-Ganz catheter was inserted to measure the pulmonary vascular resistance index (PVRI) before the operation, and SvO2 greater than 70% of the internal jugular vein was maintained during ECLS. The ECLS system was implanted under full heparinization, and heparin titration was performed with bedside measurement of activated partial thromboplastin time (aPTT, target value 1.5 to 2.5 times normal) every 4 h (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Postcardiac transplantation management and antirejection medical therapy were based on the 2010 guidelines for the care of heart transplantation recipients (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDefinition\u003c/strong\u003e \u003cp\u003e1. Refractory cardiogenic shock: Shock and organ insufficiency caused by low cardiac output despite optimal drug support (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePerioperative definition: the period from VA-ECMO maintenance to the time when patients were discharged from the ICU and can receive rehabilitation after heart transplantation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDischarged from ICU standard: No organ function support is required (blood pressure is stable without vasoactive drugs, and the patient has ventilator independence, stable kidney and liver functions, with no potential infection)\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDischarged from cardiac surgery: the concentration of tacrolimus (FK-506) in the blood was stable; the wound healed well; there was no potential risk of infection; and regular outpatient follow-up was achieved.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, all 12 patients were male, with an average age of 45.33 years and an average BMI of 22.87 kg/m2. The primary diseases distributed among the patients were myocardial infarction (7 cases), and all of the myocardial infarction patients underwent coronary artery angiography (CAG), which showed 3-vessel coronary artery disease (CAD), and the culprit vessel was reperfused; dilated cardiomyopathy (4 cases); and myocarditis (1 case). The average ECMO maintenance time before transplantation was 14.25 days, and the longest preoperative maintenance time was 37 days. The left ventricular ejection fraction (LVEF) was measured using the biplanar Simpson technique, and the LVEF ranged from 12\u0026ndash;32%, with an average LVEF of 23.4%. Among them, 2 patients were treated with intra-aortic balloon pumps (IABP) combined with VA-ECMO as a bridge to heart transplantation. Allograft heart transplantation was successfully performed in all 12 patients, and the average aortic cross-clamp time in the operation was 57.5 min. Nine patients survived, 3 patients died, and the overall survival rate was 75.00%. Among them, Patient 3 was considered to have primary graft failure and ultimately died of multiple organ failure on the 7th day after transplantation; Patient 7 died of a bloodstream infection and septic shock on the 67th day after the operation; and Patient 9 had a mediastinum infection and suddenly died from an ascending aorta rupture (intraoperatively, the incision was 0.5 cm above the anastomosis, and the mediastinal infection eroded the blood vessels). The total perioperative ECMO survival rate was 75.00%, and the 30-day survival rate was 91.67%.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePatient characteristics.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePrimary disease\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003esex\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eage\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eBMI(kg/m2)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eDemographics and comorbidity\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePrevious CAG\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emyocardial infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esmoking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3-vessel CAD\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003efulminant myocarditis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e27.04\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esmoking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAG negative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003edilated cardiomyopathy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAG negative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emyocardial infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e37\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esmoking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3-vessel CAD\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emyocardial infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21.25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ediabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3-vessel CAD\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emyocardial infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e21.22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003esmoking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3-vessel CAD\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emyocardial infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e35\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e27.68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ediabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3-vessel CAD\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003edilated cardiomyopathy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e27.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAG negative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003edilated cardiomyopathy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e59\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.76\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAG negative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003edilated cardiomyopathy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18.36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCAG negative\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emyocardial infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22.49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ediabetes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3-vessel CAD\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003emyocardial infarction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e20.41\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3-vessel CAD\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003e(continued)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eECMO mode\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCatheter Site\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCatheter size\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eDPC size\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePreoperative ECMO maintenance time\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eECMO\u0026thinsp;+\u0026thinsp;IABP\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eLeft ventricular unloading\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVenous cannula\u003c/p\u003e\n\u003cp\u003e(femoral vein)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eArtery cannula\u003c/p\u003e\n\u003cp\u003e(femoral artery)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVenous cannula\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eArtery cannula\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.5Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNewly diagnosed HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epreoperation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNewly diagnosed HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKnown chronic HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.5Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNewly diagnosed HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNewly diagnosed HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNewly diagnosed HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNewly diagnosed HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-AV ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epreoperation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKnown chronic HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAlready on the waiting list\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAlready on the waiting list\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-AV ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNewly diagnosed HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eV-A ECMO\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8Fr\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNewly diagnosed HF\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1. (continued)\u003c/p\u003e\n\u003ctable border=\"1\" width=\"589\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003ePreoperative Intubation time\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003ePreoperative Renal replacement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003eEF\u003c/p\u003e\n\u003cp\u003eCalculated\u003c/p\u003e\n\u003cp\u003eBy echocardiography\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003ePVRI（wood unit）\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003eIntraoperative aortic cross-clamp time (minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e6 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e28%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e67 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e14 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e15%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e4.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e72 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e6 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e3.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e52 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e51 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e21%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e2.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e48 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e26 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e28%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e65 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e24 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e3.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e43 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e11 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e12%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e4.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e56 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e11 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e24%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e4.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e67 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e30 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e20%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e4.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e66 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e3 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e26%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e5.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e49 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e15 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e28%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e4.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e51 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"77\"\u003e\n\u003cp\u003ePatient 12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"91\"\u003e\n\u003cp\u003e12 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"93\"\u003e\n\u003cp\u003eyes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"117\"\u003e\n\u003cp\u003e32%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"97\"\u003e\n\u003cp\u003e3.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"114\"\u003e\n\u003cp\u003e54 min\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHF=Heart Failure; DPC= distal perfusion cannulas\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 12 patients who underwent VA-ECMO bridged to heart transplantation (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), the femoral vessels were the preferred access points in the patients, and different catheter sizes were selected according to the target vessels\u0026rsquo; diameters, as were the DPC catheters. Lower extremity ischemia (LEI) occurred in 3 patients, and 1 of the 3 patients with LEI even required lower extremity fasciotomy (LEF). Except for the ECMO cannulation site, the bleeding manifestations we observed were mainly related to gastrointestinal bleeding, and 4 patients had postoperative bleeding requiring reoperation, but postoperative bleeding did not appear to be necessarily associated with patient outcomes. In addition to monitoring, ECMO-related complications mainly manifested as poor healing at the cannulation insertion site (5 cases). Average total length of ICU stay: 52.25 days. It seemed that poor healing at the insertion site was not related to catheter size or comorbidity.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePerioperative ECMO-related complications and outcomes in patients bridged to transplantation.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eComplications\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eICU-stay length\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eOutcomes\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003epredischarge echocardiographic data\u003c/p\u003e\n\u003c/th\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLVEF (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTAPSE (mm)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLEI\u0026thinsp;+\u0026thinsp;LEF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGastrointestinal bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDied\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDied because of PGD, CS, result in MOF at 7 days post-HT\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLEI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReoperation for bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e105 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e60\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInsertion site poor healing\u0026thinsp;+\u0026thinsp;Gastrointestinal bleeding\u0026thinsp;+\u0026thinsp;Reoperation for bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLEI\u0026thinsp;+\u0026thinsp;Insertion site poor healing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e67 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDied\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDied of a blood infection after pressure ulcer debridement\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInsertion site poor healing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInsertion site poor healing\u0026thinsp;+\u0026thinsp;Gastrointestinal bleeding\u0026thinsp;+\u0026thinsp;Reoperation for bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDied\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDied of an ascending aorta rupture after mediastinum infection\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReoperation for bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e55\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInsertion site poor healing\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e68\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePatient 12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGastrointestinal bleeding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 days\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDischarge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e65\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"7\"\u003e(LEI\u0026thinsp;=\u0026thinsp;lower extremity ischemia; LEF\u0026thinsp;=\u0026thinsp;lower extremity fasciotomy; PGD\u0026thinsp;=\u0026thinsp;primary graft dysfunction; CS\u0026thinsp;=\u0026thinsp;cardiogenic shock; MOF\u0026thinsp;=\u0026thinsp;multiple organ failure)\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eBefore the patients were discharged, echocardiography was used to assess LVEF and tricuspid annular plane systolic excursion (TAPSE), and the average LVEF was 62.78% and TAPSE was 14.3 mm.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eIn the past few decades, VA-ECMO has been increasingly developed and applied and is widely used in clinical practice. Its function of supporting clinical hemodynamics and assisting gas exchange is important for clinical diagnosis, treatment, and organ recovery. VA-ECMO increases survival and has great benefits (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). At present, VA-ECMO has become an important rescue measure for critically ill patients, especially those with refractory cardiogenic shock who are transitioning to recovery or have undergone transplantation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this paper, 12 patients whose heart function could not be recovered after VA-ECMO could not be weaned from ECMO and were directly bridged to heart transplantation, and we found that the postoperative survival rate was 75.00%. It has been reported in the literature that the survival rate in patients receiving short-term VA-ECMO as a bridge to heart transplantation can reach 50% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), and the prognosis is not significantly different from survival after heart transplantation in common recipients (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In their series, the 1-year survival rate of 13 patients who received ECMO support after transplantation (1 with postoperative shock, 8 with cardiomyopathy, and 4 with acute myocardial infarction) as a bridge to transplantation was 51%. However, the duration of ECMO support before transplantation has not been described. Our data focused on the peri-operative time in those patients, and none of them died before undergoing heart transplantation, which was an amazing result compared to that of Poptsov\u0026rsquo;s study (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), despite having a much smaller sample of patients. In addition, the 30-day survival rate was 91.67%, which was higher than previously reported values.\u003c/p\u003e \u003cp\u003eThe average maintenance time of preoperative ECMO support in our case series was 14.25 days. There have been reports in the literature suggesting that during the bridging process, the maintenance time of VA-ECMO ranges from 7 to 14 days. However, the longest maintenance time in our patients was 37 days, which is longer than that reported in previous studies (\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe main perioperative ECMO-related complications in 12 patients bridged to transplant included gastrointestinal bleeding, limb ischemia with or without fasciotomy, bleeding after transplantation in the operative area that requires reoperation to stop the bleeding, and poor healing around the puncture wound after ECMO was removed, which was common after weaning from ECMO support, and it has been reported that these complications might affect the outcomes (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, in our case series, we did not find a relationship between the complications. Therefore, due to the small sample size, it remains unclear whether perioperative complications are associated with the outcome.\u003c/p\u003e \u003cp\u003eIn conclusion, as the utilization of temporary MCS devices, including IABP, percutaneous ventricular assist devices (pVADs) and ECMO, has become increasingly common, the proportion of patients bridged directly to heart transplantation has exponentially increased. Compared to other MCS devices, ECMO provides a more stable flow for CS patients and is widely used in patients with unstable cardiac electrical activity (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Although we did not have any experience with other MCS devices bridged to heart transplantation, the outcomes in patients with ECMO were satisfactory. VA-ECMO should be regarded as a bridge to emergency heart transplantation. However, ECMO-related complications are also our focus.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study have been performed in accordance with the Declaration of Helsinki, and was approved by the Medical Research Ethics committee of the First Affiliated Hospital, \u0026nbsp;Zhejiang University School of Medicine. Written informed consent was obtained from all individual participants or from the legal representative (i.e., spouse or first-degree relatives) if the participants deceased.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated during and analyzed during the current study are not publicly available due to the privacy of individuals that participated in the study but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors declare competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is not funded by any grant.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Xing Fang , Dr. Jueyan Yan and Dr. Tong Li wrote the main manuscript text and Dr. Zhipeng Xu and Dr. Jingchen Zhang prepared figures and tables. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eConrad N, Judge A, Tran J, Mohseni H, Hedgecott D, Crespillo AP, et al. Temporal trends and patterns in heart failure incidence: a population-based study of 4 million individuals. Lancet. 2018;391:572\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0140-6736(17)32520-5\u003c/span\u003e\u003cspan address=\"10.1016/s0140-6736(17)32520-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoth GA, Forouzanfar MH, Moran AE, Barber R, Nguyen G, Feigin VL, et al. Demographic and epidemiologic drivers of global cardiovascular mortality. 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J Thorac Dis. 2021;13:6911\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/jtd-21-832\u003c/span\u003e\u003cspan address=\"10.21037/jtd-21-832\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"heart transplantation, extracorporeal circulation support, ECMO, complications, outcomes","lastPublishedDoi":"10.21203/rs.3.rs-4184890/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4184890/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Cardiogenic shock (CS) is characterized by end-organ hypoperfusion resulting from low cardiac output. Venous-artery extracorporeal membrane oxygenation (VA-ECMO), is widely used in patients presenting with refractory cardiogenic shock. The decision to use VA-ECMO as a bridge to heart transplantation has become widely accepted as a short-term option. However, complications can develop within weeks, which makes it unsuitable for bridging to transplantation and even affects the prognosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods：\u003c/strong\u003eData were collected from 12 patients who received extracorporeal membrane oxygenation (ECMO) as a bridge to heart transplantation between October 2020 and October 2021. General perioperative characteristics, ECMO-related complications, and posttransplantation survival were summarized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults：\u003c/strong\u003eThe 12 patients were male, with an average age of 45.33 years and an average BMI of 22.87 kg/m2. The main primary diseases were myocardial infarction (7 cases), dilated cardiomyopathy (4 cases), and fulminant myocarditis (1 case); the average ECMO maintenance time before transplantation was 14.25 days, the longest preoperative maintenance time was 37 days, the overall ECMO perioperative survival rate was 75.00%, and the 30-day survival rate was 91.67%. The main complications in the perioperative period are gastrointestinal bleeding, distal limb ischemia of the perfusion tube and distal limb ischemia requiring fasciotomy during ECMO maintenance, bleeding after transplantation in the operative area requiring reoperation for bleeding, and poor healing at the ECMO cannulation insertion site.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion：\u003c/strong\u003eECMO as a bridge to heart transplantation is a feasible treatment option for patients with end-stage heart failure and refractory cardiogenic shock. We should be aware of the complications related to ECMO management.\u003c/p\u003e","manuscriptTitle":"Perioperative Complications and Outcomes of 12 Patients Bridged to Heart Transplantation by Extracorporeal Membrane Oxygenation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-09 13:24:18","doi":"10.21203/rs.3.rs-4184890/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a734855-dda4-4c21-808f-12b8a6ee7984","owner":[],"postedDate":"April 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-17T04:06:08+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-09 13:24:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4184890","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4184890","identity":"rs-4184890","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}