OBJECTIVES: Postcardiotomy extracorporeal membrane oxygenation (ECMO) can be initiated intraoperatively or postoperatively based on indications, settings, patient profile, and conditions. The topic of implantation timing only recently gained attention from the clinical community. We compare patient characteristics as well as in-hospital and long-term survival between intraoperative and postoperative ECMO. METHODS: The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support (PELS-1) study includes adults who required ECMO due to postcardiotomy shock between 2000 and 2020. We compared patients who received ECMO in the operating theater (intraoperative) with those in the intensive care unit (postoperative) on in-hospital and postdischarge outcomes. RESULTS: We studied 2003 patients (women: 41.1%; median age: 65 years; interquartile range [IQR], 55.0-72.0). Intraoperative ECMO patients (n = 1287) compared with postoperative ECMO patients (n = 716) had worse preoperative risk profiles. Cardiogenic shock (45.3%), right ventricular failure (15.9%), and cardiac arrest (14.3%) were the main indications for postoperative ECMO initiation, with cannulation occurring after (median) 1 day (IQR, 1-3 days). Compared with intraoperative application, patients who received postoperative ECMO showed more complications, cardiac reoperations (intraoperative: 19.7%; postoperative: 24.8%, P = .011), percutaneous coronary interventions (intraoperative: 1.8%; postoperative: 3.6%, P = .026), and had greater in-hospital mortality (intraoperative: 57.5%; postoperative: 64.5%, P = .002). Among hospital survivors, ECMO duration was shorter after intraoperative ECMO (median, 104; IQR, 67.8-164.2 hours) compared with postoperative ECMO (median, 139.7; IQR, 95.8-192 hours, P < .001), whereas postdischarge long-term survival was similar between the 2 groups (P = .86). CONCLUSIONS: Intraoperative and postoperative ECMO implantations are associated with different patient characteristics and outcomes, with greater complications and in-hospital mortality after postoperative ECMO. Strategies to identify the optimal location and timing of postcardiotomy ECMO in relation to specific patient characteristics are warranted to optimize in-hospital outcomes.

2 Department of Anesthesiology Centre of Anesthesia Intensive Care and Pain management Vilnius University Hospital Santariskiu Klinikos Vilnius Lithuania

2nd Department of Internal Medicine Cardiovascular Medicine General Teaching Hospital and 1st Faculty of Medicine Charles University Prague Prague Czech Republic

Adult Intensive Care Services The Prince Charles Hospital Brisbane Australia

Cardiac Intensive Care Unit Johns Hopkins Hospital Baltimore Md

Cardiac Surgery Unit Cardiac Thoracic and Vascular Department Niguarda Hospital Milan Italy

Cardiac Surgery Unit IRCCS Humanitas Research Hospital Rozzano Italy

Cardio Thoracic Surgery Department Maastricht University Medical Center and Cardiovascular Research Institute Maastricht Maastricht The Netherlands

Cardiothoracic Intensive Care Unit National University Heart Centre National University Hospital Singapore Singapore

Center for Cardiac Intensive Care Beijing Institute of Heart Lung and Blood Vessels Diseases Beijing Anzhen Hospital Beijing China

Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione Palermo Italy

Department of Cardiac Surgery Leipzig Heart Center Leipzig Germany

Department of Cardiac Surgery Louis Pradel Cardiologic Hospital Lyon France

Department of Cardiac Surgery Medical Faculty Heinrich Heine University Duesseldorf Germany

Department of Cardiac Surgery Medical University of Vienna Vienna Austria

Department of Cardiac Surgery University Hospitals Leuven and Department of Cardiovascular Sciences University of Leuven Leuven Belgium

Department of Cardio Thoracic Surgery University Hospital Henri Mondor Créteil Paris France

Department of Cardiology Fundación Cardiovascular de Colombia Bucaramanga Colombia

Department of Cardiothoracic Surgery University Medical Center Regensburg Regensburg Germany

Department of Cardiovascular Surgery Ziekenhuis Oost Limburg Genk Belgium

Department of Intensive Care Adults Erasmus MC Rotterdam The Netherlands

Department of Intensive Care Medicine Center of Applied Medical Research St Vincent's Hospital Darlinghurst Australia

Department of Intensive Care Medicine Maastricht University Medical Center and Cardiovascular Research Institute Maastricht Maastricht The Netherlands

Department of Medicine and Surgery Cardiac Surgery Clinic San Gerardo Hospital University of Milano Bicocca Monza Italy and Department of Medicine and Surgery University of Parma Cardiac Surgery Unit University Hospital of Parma Parma Italy

Department of Thoracic and Cardiovascular Surgery Korea University Anam Hospital Seoul South Korea

Departments of Medicine and Surgery University of Maryland Baltimore Md

Division of Cardiac Surgery Cardiothoracic Department University Hospital of Udine Udine Italy

Division of Cardiac Surgery IRCCS Azienda Ospedaliero Universitaria di Bologna Bologna Italy

Division of Cardiac Surgery Memorial Healthcare System Hollywood Calif

Division of Cardiothoracic and Vascular Surgery Pontchaillou University Hospital Rennes France

Division of Cardiovascular and Thoracic Surgery Department of Surgery Faculty of Medicine Siriraj Hospital Bangkok Thailand

ECMO Unit Departamento de Anestesia Clínica Las Condes Santiago Chile

Intensive Care Unit The Alfred Hospital Melbourne Australia

IU Health Advanced Heart and Lung Care Indiana University Methodist Hospital Indianapolis Ind

Ospedale del Cuore Fondazione Toscana G Monasterio Massa Italy

SOD Cardiochirurgia Ospedali Riuniti 'Umberto 1 Lancisi Salesi' Università Politecnica delle Marche Ancona Italy

J Thorac Cardiovasc Surg. 2023 Dec;166(6):1683. doi: 10.1016/j.jtcvs.2023.05.008 PubMed

Characteristics and Outcomes of Prolonged Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery: The Post-Cardiotomy Extracorporeal Life Support (PELS-1) Cohort Study