BACKGROUND: Postcardiotomy venoarterial extracorporeal membrane oxygenation (VA ECMO) is characterized by discrepancies between weaning and survival-to-discharge rates. This study analyzes the differences between postcardiotomy VA ECMO patients who survived, died on ECMO, or died after ECMO weaning. Causes of death and variables associated with mortality at different time points are investigated. METHODS: The retrospective, multicenter, observational Postcardiotomy Extracorporeal Life Support Study (PELS) includes adults requiring postcardiotomy VA ECMO between 2000 and 2020. Variables associated with on-ECMO mortality and postweaning mortality were modeled using mixed Cox proportional hazards, including random effects for center and year. RESULTS: In 2058 patients (men, 59%; median age, 65 years; interquartile range [IQR], 55-72 years), weaning rate was 62.7%, and survival to discharge was 39.6%. Patients who died (n = 1244) included 754 on-ECMO deaths (36.6%; median support time, 79 hours; IQR, 24-192 hours), and 476 postweaning deaths (23.1%; median support time, 146 hours; IQR, 96-235.5 hours). Multiorgan (n = 431 of 1158 [37.2%]) and persistent heart failure (n = 423 of 1158 [36.5%]) were the main causes of death, followed by bleeding (n = 56 of 754 [7.4%]) for on-ECMO mortality and sepsis (n = 61 of 401 [15.4%]) for postweaning mortality. On-ECMO death was associated with emergency surgery, preoperative cardiac arrest, cardiogenic shock, right ventricular failure, cardiopulmonary bypass time, and ECMO implantation timing. Diabetes, postoperative bleeding, cardiac arrest, bowel ischemia, acute kidney injury, and septic shock were associated with postweaning mortality. CONCLUSIONS: A discrepancy exists between weaning and discharge rate in postcardiotomy ECMO. Deaths occurred during ECMO support in 36.6% of patients, mostly associated with unstable preoperative hemodynamics. Another 23.1% of patients died after weaning in association with severe complications. This underscores the importance of postweaning care for postcardiotomy VA ECMO patients.

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 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 Maryland

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

Cardiac Surgery Unit IRCCS Humanitas Research Hospital Rozzano Milan Italy

Cardiac Surgery Unit San Gerardo Hospital Monza Italy; Cardiac Surgery Unit Department of Medicine and Surgery University Hospital of Parma University of Parma Parma Italy

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

Cardiovascular Research Institute Maastricht Maastricht the Netherlands; Department of Intensive Care Medicine Maastricht University Medical Center Maastricht the Netherlands

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

Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation IRCCS ISMETT Palermo Italy

Department of Cardiac Surgery Heinrich Heine University Duesseldorf Germany

Department of Cardiac Surgery Leipzig Heart Center Leipzig Germany

Department of Cardiac Surgery Louis Pradel Cardiologic Hospital Lyon France

Department of Cardiac Surgery Medical University of Vienna Vienna Austria

Department of Cardiac Surgery University Hospitals Leuven Leuven Belgium

Department of Cardio Thoracic Surgery Maastricht University Medical Center Maastricht the Netherlands

Department of Cardio Thoracic Surgery Maastricht University Medical Center Maastricht the Netherlands; Cardiovascular Research Institute Maastricht Maastricht the Netherlands

Department of Cardio Thoracic Surgery Maastricht University Medical Center Maastricht the Netherlands; Department of Cardiac Surgery University Hospitals 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 Cardiology Erasmus MC Rotterdam the Netherlands

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

Department of Medicine University of Maryland Baltimore Maryland; Department of Surgery University of Maryland Baltimore Maryland

Department of Thoracic and Cardiovascular Surgery Korea University College of Medicine Seoul South Korea

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

Division of Cardiac Surgery IRCCS Azienda Ospedaliero Universitaria di Bologna Bologna Italy; Department of Surgical Sciences University of Turin Turin Italy

Division of Cardiac Surgery Memorial Healthcare System Hollywood Florida

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

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

Intensive Care Unit The Alfred Hospital Melbourne Victoria Australia

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

Ospedale del Cuore Fondazione Toscana G Monasterio Massa Italy

Struttura Organizzativa Dipartimentale Cardiochirurgia Ospedali Riuniti 'Umberto 1 Lancisi Salesi' Università Politecnica delle Marche Ancona Italy

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