• Silvia Mariani, I-Wen Wang, Bas C T van Bussel, Samuel Heuts, Dominik Wiedemann, Diyar Saeed, van der HorstIwan C CICCDepartment of Intensive Care Medicine, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands., Matteo Pozzi, Antonio Loforte, Udo Boeken, Robertas Samalavicius, Karl Bounader, Xiaotong Hou, BungeJeroen J HJJHDepartment of Intensive Care Adults, Erasmus MC, Rotterdam, The Netherlands., Hergen Buscher, Leonardo Salazar, Bart Meyns, Daniel Herr, Sacha Matteucci, Sandro Sponga, Kollengode Ramanathan, Claudio Russo, Francesco Formica, Pranya Sakiyalak, Antonio Fiore, Daniele Camboni, Giuseppe Maria Raffa, Rodrigo Diaz, Jae-Seung Jung, Jan Belohlavek, Vin Pellegrino, Giacomo Bianchi, Matteo Pettinari, Alessandro Barbone, José P Garcia, Kiran Shekar, Glenn Whitman, Roberto Lorusso, and PELS-1 (PELS-1, Post-Cardiotomy Extracorporeal Life Support Study) Investigators.
• Cardio-Thoracic Surgery Department, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht (CAIRM), Maastricht, The Netherlands. Electronic address: s.mariani1985@gmail.com.
• J. Thorac. Cardiovasc. Surg. 2023 Dec 1; 166 (6): 16701682.e331670-1682.e33.

ObjectivesPostcardiotomy 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.MethodsThe 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.ResultsWe 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).ConclusionsIntraoperative 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.Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.

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