Matteo Pozzi

Background and Aims: Refractory advanced biventricular heart failure (RAHF) has a poor prognosis, and many patients are ineligible for left ventricular assist device (LVAD) support. The ‘historical’ total artificial heart (TAH) is associated with high rates of stroke, bleeding, and haemolysis. The bioprosthetic TAH (bio-TAH), a pulsatile, auto-regulated, and haemocompatible device, was assessed here as a bridge to transplantation. Methods: EFICAS (NCT04475393) was a prospective, multi-centre trial conducted at 10 French centres. Adults with RAHF who were ineligible for LVAD support and listed or eligible for heart transplantation were enrolled. The primary composite endpoint was survival at 180 days free from disabling stroke, device malfunction requiring reoperation or urgent transplantation, or elective heart transplantation. Secondary endpoints included serious adverse events, New York Heart Association (NYHA) class, the 6-min walk test, and quality-of-life measured using the EQ-5D-5L. Results: Fifty-five patients underwent implantation (December 2022 and May 2025; median age, 56 years [IQR, 48–63]; 49% INTERMACS profiles 1–2; 36% on venoarterial extracorporeal membrane oxygenation). The primary endpoint was achieved in 40 patients (72.7%; 95% confidence interval, 57.1–85.1), exceeding the pre-specified ‘historical TAH’ threshold of 38% (P < .0001). At 180 days, 96% were free of disabling stroke, 76% were discharged, and 92% were NYHA class I-II. Median 6-minute walk distance improved by 305 m (P = .0002) and EQ-5D by 40 points (P < .0001). No haemolysis occurred, and major bleeding was limited to the first 30 days. Conclusions: The bio-TAH achieved its primary endpoint with a favourable safety profile, supporting its use as an effective bridge-to-transplant strategy in patients with RAHF ineligible for LVAD support.

Background: While guideline-directed medical therapy (GDMT) is recommended for left ventricular assist device (LVAD) recipients, real-world evidence supporting its clinical impact remains limited. This study evaluated the association between GDMT prescription and clinical outcomes in LVAD patients. Methods: This international retrospective multicentre study included 875 LVAD patients from 22 centres. Patients were categorized based on the number of GDMT (ACE-I/ARBs, beta-blockers, MRAs) prescribed. Primary outcome was 6-month all-cause mortality. Secondary outcome was late ventricular arrhythmias (VAs) (>30 days post-implant). Multivariable Cox regression and ordinal logistic regression analyses were performed. Results: Overall, only 261 patients (29.8%) received triple GDMT, while 97 (11.1%) received no GDMT. After multivariable adjustment, the number of prescribed GDMTs was independently associated with improved survival, with aHRs for all-cause mortality of 0.51 (0.33–0.75, P < .01) for triple therapy, 0.39 (0.26–0.59, P < .01) for dual therapy, and 0.45 (0.30–0.67, P < .01) for single therapy, all compared with no GDMT. Similarly, ACE-I/ARB were associated with a lower risk of late VAs (aHR 0.65 [0.50–0.84], P < .01). Female sex, diabetes, early VAs, and higher bilirubin levels were associated with lower GDMT prescription rates. Major LVEDD improvement (≥10 mm reduction) increased progressively from 51.5% without GDMT to 66.1% with triple therapy. Conclusion: In this large international study, the use of GDMT in LVAD patients was associated with improved survival, with benefits observed even with single-agent therapy. Despite these benefits, only 30% of patients received optimal triple therapy, highlighting the need for improved implementation strategies and standardized protocols in this population.

L’insuffisance cardiaque aigue est une émergence médicale qui nécessite une prise en charge multidisciplinaire. L’Extracorporeal Life Support (ECLS) peut être envisagé comme option thérapeutique pour les formes d’insuffisance cardiaque aigue réfractaire au traitement conventionnel. L’objectif de ce projet de recherche clinique est de fournir une vue d’ensemble de l’ECLS dans la prise en charge du choc cardiogénique et de l’arrêt cardiaque réfractaire. L’intoxication médicamenteuse et la myocardite sont les meilleures indications à l’implantation de l’ECLS en considération de leur potentiel de récupération myocardique très élevé. La défaillance primaire du greffon après transplantation cardiaque et l’infarctus du myocarde présentent des résultats plus mitigés avec l’ECLS en raison d’une physiopathologie plus complexe. Le choc cardiogénique postcardiotomie après une intervention de chirurgie cardiaque montre des résultats décevants en raison du profile préopératoire des patients. L’arrêt cardiaque aussi exige une prise en charge immédiate et l’ECLS peut être considéré comme une solution thérapeutique de sauvetage. Une meilleure sélection des patients s’impose afin d’améliorer les résultats de l’ECLS pour l’arrêt cardiaque réfractaire intrahospitalier. Les résultats de l’ECLS pour l’arrêt cardiaque réfractaire extrahospitalier sont dictés principalement par le temps de réanimation cardio-pulmonaire et le rythme cardiaque. Les rythmes non choquables pourraient être considérés comme une contre-indication formelle à l’utilisation de l’ECLS autorisant une concentration de nos efforts sur les rythmes choquables où les chances de survie sont plus importantes

Background: Extracorporeal cardiopulmonary resuscitation (ECPR) is a potential intervention for refractory in‐hospital cardiac arrest (IHCA). This study aimed to evaluate the outcomes of ECPR in patients with refractory IHCA at a university‐affiliated tertiary care center. Methods: We performed a retrospective, observational analysis of an institutional database of adult patients who received ECPR for refractory IHCA from January 2007 to December 2023. The primary endpoint was survival to hospital discharge with a favorable neurological outcome, defined as a Cerebral Performance Category (CPC) score of 1 or 2. Patients with a CPC score of 1–2 were compared to those with a CPC score ≥ 3. Results: During the study period, 147 patients received ECPR for refractory IHCA (mean age 51.0 years, 64.6% male). Baseline characteristics were comparable between both groups. Mean no‐flow time and low‐flow time and the rate of shockable rhythms were comparable between both groups. Eighty‐nine (60.5%) patients died during temporary mechanical circulatory support. Among the 56 (38.1%) patients who were weaned from mechanical circulatory support, 24 (16.3%) died before hospital discharge. The overall survival to discharge was 22.4%, with 20.4% achieving a CPC score of 1–2. Conclusions: Owing to the invariably fatal nature of refractory IHCA, ECPR offered a reasonable survival with a favorable neurological outcome in this critically ill patients' population.

Objectives: Post‐cardiotomy extracorporeal life support (ECLS) cannulation might occur in a general post‐operative ward due to emergent conditions. Its characteristics have been poorly reported and investigated This study investigates the characteristics and outcomes of adult patients receiving ECLS cannulation in a general post‐operative cardiac ward.Methods: The Post‐cardiotomy Extracorporeal Life Support (PELS) is a retrospective (2000–2020), multicenter (34 centers), observational study including adult patients who required ECLS for post‐cardiotomy shock. This PELS sub‐analysis analyzed patients´ characteristics, in‐hospital outcomes, and long‐term survival in patients cannulated for veno‐arterial ECLS in the general ward, and further compared in‐hospital survivors and non‐survivors.Results: The PELS study included 2058 patients of whom 39 (1.9%) were cannulated in the general ward. Most patients underwent isolated coronary bypass grafting (CABG, n = 15, 38.5%) or isolated non‐CABG operations (n = 20, 51.3%). The main indications to initiate ECLS included cardiac arrest (n = 17, 44.7%) and cardiogenic shock (n = 14, 35.9%). ECLS cannulation occurred after a median time of 4 (2–7) days post‐operatively. Most patients' courses were complicated by acute kidney injury (n = 23, 59%), arrhythmias (n = 19, 48.7%), and postoperative bleeding (n = 20, 51.3%). In‐hospital mortality was 84.6% (n = 33) with persistent heart failure (n = 11, 28.2%) as the most common cause of death. No peculiar differences were observed between in‐hospital survivors and nonsurvivors.Conclusions: This study demonstrates that ECLS cannulation due to post‐cardiotomy emergent adverse events in the general ward is rare, mainly occurring in preoperative low‐risk patients and after a postoperative cardiac arrest. High complication rates and low in‐hospital survival require further investigations to identify patients at risk for such a complication, optimize resources, enhance intervention, and improve outcomes.