BACKGROUND: High-quality evidence for post-cardiotomy extracorporeal life support (PC-ECLS) management is lacking. This study investigated the real-world PC-ECLS clinical practices. METHODS: This cross-sectional, multi-institutional, international pilot survey explored center organization, anticoagulation management, left ventricular unloading, distal limb perfusion, PC-ECLS monitoring and transfusions practices. Twenty-nine questions were distributed among 34 hospitals participating in the Post-cardiotomy Extra-Corporeal Life Support Study. RESULTS: Of the 32 centers [16 low-volume (50%); 16 high-volume (50%)] that responded, 16 (50%) had dedicated ECLS specialists. Twenty-six centers (81.3%) reported using additional mechanical circulatory supports. Anticoagulation practices were highly heterogeneous: 24 hospitals (75%) reported using patient's bleeding status as a guide, without a specific threshold in 54.2% of cases. Transfusion targets ranged 7-10 g/dL. Most centers used cardiac venting on a case-by-case basis (78.1%) and regular distal limb perfusion (84.4%). Nineteen (54.9%) centers reported dedicated monitoring protocols including daily echocardiography (87.5%), Swan-Ganz catheterization (40.6%), cerebral near-infrared spectroscopy (53.1%) and multimodal assessment of limb ischemia. Inspection of the circuit (71.9%), oxygenator pressure drop (68.8%), plasma free hemoglobin (75%), d-dimer (59.4%), lactate dehydrogenase (56.3%) and fibrinogen (46.9%) are used to diagnose hemolysis and thrombosis. CONCLUSIONS: This study shows remarkable heterogeneity in clinical practices for PC-ECLS management. More standardized protocols and better implementation of available evidence are recommended.

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

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

Adult Intensive Care Services The Prince Charles Hospital Brisbane Australia

Cardiac Intensive Care Unit Johns Hopkins Hospital Baltimore Maryland USA

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 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 Capital Medical University Beijing China

Central Clinical Hospital of the Ministry of Interior Centre of Postgraduate Medical Education Warsaw Poland

Clinic of Internal Medicine Department of Cardiac Surgery University of Szeged Szeged Hungary

Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS ISMETT 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 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 and Department of cardiology Erasmus MC Rotterdam The Netherlands

Department of Intensive Care Medicine and Care and Public Health Research Institute Maastricht The Netherlands

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

Department of Medicine and Surgery Cardiac Surgery Clinic San Gerardo Hospital University of Milano Bicocca Monza Italy; 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 College of Medicine Seoul South Korea

Departments of Medicine and Surgery University of Maryland Baltimore USA

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 Medical University of Vienna Vienna Austria

Division of Cardiac Surgery Memorial Healthcare System Hollywood FL USA

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 Mahidol University Bangkok Thailand

ECLS Unit Departamento de Anestesia Clínica Las Condes Las Condes Santiago Chile

Intensive Care Unit The Alfred Hospital Melbourne VIC Australia

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

Ospedale del Cuore Fondazione Toscana G Monasterio Massa Italy

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

University of Turin Department of Surgical Sciences Turin Italy

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Neurologic complications in patients receiving aortic versus subclavian versus femoral arterial cannulation for post-cardiotomy extracorporeal life support: results of the PELS observational multicenter study