The use of extracorporeal life support (ECLS) devices has significantly increased in the last decades. Despite medical and technological advancements, a main challenge in the ECLS field remains the complex interaction between the human body, blood, and artificial materials. Indeed, blood exposure to artificial surfaces generates an unbalanced activation of the coagulation cascade, leading to hemorrhagic and thrombotic events. Over time, several anticoagulation and coatings methods have been introduced to address this problem. This narrative review summarizes trends, advantages, and disadvantages of anticoagulation and coating methods used in the ECLS field. Evidence was collected through a PubMed search and reference scanning. A group of experts was convened to openly discuss the retrieved references. Clinical practice in ECLS is still based on the large use of unfractionated heparin and, as an alternative in case of contraindications, nafamostat mesilate, bivalirudin, and argatroban. Other anticoagulation methods are under investigation, but none is about to enter the clinical routine. From an engineering point of view, material modifications have focused on commercially available biomimetic and biopassive surfaces and on the development of endothelialized surfaces. Biocompatible and bio-hybrid materials not requiring combined systemic anticoagulation should be the future goal, but intense efforts are still required to fulfill this purpose.

Background: Extracorporeal membrane oxygenation (ECMO) has been increasingly used for postcardiotomy cardiogenic shock, but without a concomitant reduction in observed in‐hospital mortality. Long‐term outcomes are unknown. This study describes patients’ characteristics, in‐hospital outcome, and 10‐year survival after postcardiotomy ECMO. Variables associated with in‐hospital and postdischarge mortality are investigated and reported. Methods and Results: The retrospective international multicenter observational PELS‐1 (Postcardiotomy Extracorporeal Life Support) study includes data on adults requiring ECMO for postcardiotomy cardiogenic shock between 2000 and 2020 from 34 centers. Variables associated with mortality were estimated preoperatively, intraoperatively, during ECMO, and after the occurrence of any complications, and then analyzed at different time points during a patient's clinical course, through mixed Cox proportional hazards models containing fixed and random effects. Follow‐up was established by institutional chart review or contacting patients. This analysis included 2058 patients (59% were men; median [interquartile range] age, 65.0 [55.0–72.0] years). In‐hospital mortality was 60.5%. Independent variables associated with in‐hospital mortality were age (hazard ratio [HR], 1.02 [95% CI, 1.01–1.02]) and preoperative cardiac arrest (HR, 1.41 [95% CI, 1.15–1.73]). In the subgroup of hospital survivors, the overall 1‐, 2‐, 5‐, and 10‐year survival rates were 89.5% (95% CI, 87.0%–92.0%), 85.4% (95% CI, 82.5%–88.3%), 76.4% (95% CI, 72.5%–80.5%), and 65.9% (95% CI, 60.3%–72.0%), respectively. Variables associated with postdischarge mortality included older age, atrial fibrillation, emergency surgery, type of surgery, postoperative acute kidney injury, and postoperative septic shock. Conclusions: In adults, in‐hospital mortality after postcardiotomy ECMO remains high; however, two‐thirds of those who are discharged from hospital survive up to 10 years. Patient selection, intraoperative decisions, and ECMO management remain key variables associated with survival in this cohort. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03857217.

Purpose: To determine the efficacy of thoracic endovascular aortic repair (TEVAR) for degenerative aneurysm involving only the descending thoracic aorta (DTAA). Methods: An English-language literature review was performed through PubMed, Scopus, and Google Scholar to identify any study evaluating the outcomes of TEVAR for DTAA. The main endpoints of this analysis were all-cause 30-day and late postoperative mortality. Secondary outcome measures were procedure success, vascular access complications, paraplegia, stroke, early endoleaks during the index hospitalization, aneurysm-related death, reinterventions, and conversion to open repair. To control for the anticipated heterogeneity among small observational studies, absolute values and means were pooled using random effects models; the results are expressed as pooled proportions, means, or risk ratio (RR) with 95% confidence intervals (CIs). Results: Eleven studies reporting on 673 patients (mean age 72.6 years, mean aneurysm diameter 62.9 cm) with DTAA were selected for the analysis. Technical success was reported in 91.0% of patients, and vascular access complications requiring repair were encountered in 9.7% of cases. Pooled overall 30-day, 1-year, 2-year, and 3-year survival rates were 96.0%, 80.3%, 77.3%, and 74.0%, respectively. Five studies compared the results of TEVAR after elective (n=151) and urgent/emergent procedure (n=77); the latter was a predictor of 30-day mortality (17.1% vs 1.8%, RR 3.83, 95% CI 1.18 to 12.40, p=0.025). Paraplegia occurred in 3.2% of patients and was permanent in 1.4% of patients. The stroke rate was 2.7%. Early type I endoleak was observed in 7.3%, type II endoleak in 2.0%, and type III in 1.2% of patients. The mean follow-up of 9 studies was 22.3 months. At 3 years, freedom from reintervention was 90.3%. Death secondary to aneurysm rupture and/or fistula was reported in 3.2% of patients. Conclusion: Current results indicate that TEVAR for DTAA can be performed with rather high technical success, low postoperative morbidity, and good 3-year survival.

Background: Thoracic aortic disease has a high mortality. We sought to establish the contribution of unwarranted variation in care to regional differences in outcomes observed in patients with thoracic aortic disease in England. Methods and Results: Data from the Hospital Episode Statistics ( HES ) and the National Adult Cardiac Surgery Audit ( NACSA ) were extracted. A parallel systematic review/meta‐analysis through December 2015, and structure and process questionnaire of English cardiac surgery units were also accomplished. Treatment and mortality rates were investigated. A total of 24 548 adult patients in the HES study, 8058 in the NACSA study, and 103 543 from a total of 33 studies in the systematic review were obtained. Treatment rates for thoracic aortic disease within 6 months of index admission ranged from 7.6% to 31.5% between English counties. Risk‐adjusted 6‐month mortality in untreated patients ranged from 19.4% to 36.3%. Regional variation persisted after adjustment for disease or patient factors. Regional cardiac units with higher case volumes treated more‐complex patients and had significantly lower risk‐adjusted mortality relative to low‐volume units. The results of the systematic review indicated that the delivery of care by multidisciplinary teams in high‐volume units resulted in better outcomes. The observational analyses and the online survey indicated that this is not how services are configured in most units in England. Conclusions: Changes in the organization of services that address unwarranted variation in the provision of care for patients with thoracic aortic disease in England may result in more‐equitable access to treatment and improved outcomes.

Post-cardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intra-operatively or post-operatively based on indications, settings, patient profile and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patients´ characteristics, in-hospital and long-term survival between intra-operative and post-operative ECMO. The retrospective, multicentre, observational Post-cardiotomy Extracorporeal Life Support (PELS-1) Study includes adults requiring ECMO due to post-cardiotomy shock between 2000 and 2020. We compare patients who received ECMO in the operating theatre (intra-operative) with those in the intensive care unit (post-operative) on in-hospital and post-discharge outcomes. We studied 2003 patients [women:41.1%; median age:65 (IQR:55.0-72.0) years]. Intra-operative (n=1287), compared to post-operative (n=716), ECMO patients had worse pre-operative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for post-operative ECMO initiation, with cannulation occurring after (median) 1 day (IQR:1-3 days). Compared to intra-operative application, post-operative ECMO showed more complications, cardiac reoperations (intra-operative:19.7%; post-operative: 24.8%, p=0.011), percutaneous coronary interventions (intra-operative:1.8%; post-operative: 3.6%, p=0.026), and had higher in-hospital mortality (intra-operative:57.5%; post-operative: 64.5%, p=0.002). Among hospital survivors, ECMO duration was shorter after intra-operative ECMO (median:104, IQR:67.8-164.2 hours) compared to post-operative ECMO (median:139.7, IQR:95.8-192 hours, p<0.001), while post-discharge long-term survival was similar between the two groups (p=0.86). Intra-operative and post-operative ECMO implantations are associated with different patients' characteristics and outcomes, with higher complications and in-hospital mortality after post-operative ECMO. Strategies to identify the optimal location and timing of post-cardiotomy ECMO in relation to specific patient's characteristics are warranted to optimize in-hospital outcomes.