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Predictors of Survival to Discharge and Ventricular Recovery after VA-ECMO Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock
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The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
and alternative outflow graft locations. Patients were implanted directly from ECMO in 17%. Results: Compared to patients implanted with an HVAD without baseline ECMO, those implanted directly from ECMO experienced a higher rate of bleeding events (0.30 vs. 0.11 events per patient year (EPPY), p value = 0.02, respectively), more renal dysfunction (0.19 vs. 0.05 EPPY, p value = 0.03) and a trend toward few cardiac arrythmias (0.19 vs. 0.07 EPPY, p value = 0.08). Overall survival at one year post implant was 81% in the non-ECMO thoracotomy group, compared to 56% in the group implanted directly from ECMO (p value = 0.0003). Conclusion: The analysis of real world use of the HVAD implanted using a thoracotomy approach demonstrates that there is significantly worse survival and adverse event profile in patients undergoing implants off ECMO. However, these results do not appear to be worse than previous reports of LVAD implants off ECMO via a sternotomy approach.
412 Mid Term Survival after VA ECMO Weaning A. Vincentelli,1 N. Rousse,1 V. Loobuyck,1 M. Moussa,2 A. Mugnier,1 J. Soquet,1 E. Robin,2 F. Juthier,1 C. Goeminne,1 and C. Banfi.1 1Cardiac Surgery, Centre Hospitalier Universitaire Regional de Lille, Lille, France; and the 2Cardiac Surgery, Anesthesiology, Centre Hospitalier Universitaire Regional de Lille, Lille, France. Purpose: The aimed of this study was to evaluate the outcome of the patients successfully weaned from ECMO after cardiac recovery. Methods: From January 2008 to January 2018, 384 patients were supported with VA ECMO for cardiogenic shock in our institution. 47.1% patients (n=181) died during support. 40.9% patients were weaned from VA-ECMO (n=157), 5.7% (n=22 were supported with a LVAD or a TAH and 6.3%patients (n=4) received a heart transplant. We prospectively followed the patients weaned from ECMO by periodic visit at our center. We analyzed survival, causes of early and late deaths and predictors for death for this population. Results: 157 patients, median age 52 years (1st and 3rd quart. 39-62), were successfully weaned from VA ECMO after a median time of 7 days of support (1st and 3rd quart. 4-10 days). Main etiologies of shock were post cardiotomy (n=57, 36.3%), acute myocardial infarction (n=39, 24.8%), pulmonary embolism (n=11, 7.0%), myocarditis (n=6, 3.8%), and acute end stage heart failure (n=6, 3.8%). During a mean follow up of 1.9 years (max 10 years), 137 patients were discharged home. Early deaths (< 3 months) were due to: septic shock (n=4), brain death (n = 4), multiple organ failure (n= 8), therapeutic limitations (n= 4). Late deaths (> 2 years from ECMO weaning) were due to septic shock (n=4), heart graft failure (n=1), unknown (n=1). Three patients underwent HTx, 2 others patients are still waiting for a HTx,. Overall one-month, 6- month and 3-years survival were respectively of 93.4 (IC: 87.7-96.5); 83.4% (IC: 75.3- 89.0) and 76.5% (IC: 65.1-84.6). By multivariate Cox analysis, ECMO duration (HR= 1.15, p=0.0002), stroke during ECMO course (HR =3.85, p=0.0015), age (HR=1.06, p=0.0008), and post cardiotomy shock (HR =3.62, p=0.0124) were independent risk factor for death. Conclusion: In our ten-year experience, patients could be successfully weaned from ECMO after a refractory shock. Most of them had a satisfactory outcome and could be discharged home. Older age, a longer duration of support, stroke and post cardiotomy shock were associated with poor outcome. Further studies are needed to evaluate the risk of recurrence of heart failure and a close follow up of those patients is mandatory.
413 Does Transport Time or Distance from Hospital Affect Survival in Extracorporeal Membrane Oxygenation (ECMO) Patients? J.S. Nelson, A. Eisenbeiss, E. Stauder, K. Graham, R. Alharethi, W. Caine, H. Smith, B. Reid, M. McCulloch, B. Rasmusson, V. Hebl and B. Kfoury. Intermountain Medical Center, Murray, UT. Purpose: Many hospitals in the United States are limited in their capabilities to treat advanced heart disease. This limitation results in patients needing to be transferred to a facility with the capacity to provide higher levels of care when ECMO support has been initiated. In this study we aim to look at whether transport time or distance impacts survival rate of implanted ECMO patients. Methods: The Artificial Heart Program’s database at Intermountain Medical Center was queried from June 2007 - 2017 for patients transported to the Intermountain facility on ECMO. Patients were stratified into two groups. Group 1: those who survived to discharge and Group 2: those who expired before discharge. Seven parameters were evaluated for significance: age, distance transported, time from initial request to arrival, transport time, whether chest compressions were performed, indication for support and type of support. A two-sample t-test was used to determine significance. Results: 50 patients met study inclusion criteria; 29 were male and 21 were female. The average age for Group 1 was 49§13 years compared to Group 2, 55 § 15 years. The average transport distance and time was 125§118 miles & 73§24 minutes for Group 1 vs 74§78 miles & 105§55 minutes for Group 2. The time from life flight request was 293§85 minutes vs 365§139 minutes for Group 1 vs Group 2. The majority of patients were implanted with CARDIOHELP (CH) (p=0.52). Additional preliminary factors such as indications for support and whether patient received chest compressions are summarized below. Conclusion: Our observations indicate that increased transport time correlates with a lower survival rate. Whereas we found no significance in the distance the patient traveled. The average distance for Group 1 was 40% farther then Group 2. This study suggests that decreasing the time from ECMO request to transportation arrival and decreasing the time of transport could lead to improved survival of ECMO patients transferred between hospitals.
Parameters Age(years) Distance(miles) Time from initial request (minutes) Transport time from bed to IMC (minutes) Compressions prior to ECMO Indication for support
Type of support
Survived (n=18)
Expired (n=32)
P-value
49§13 125§118 293§85
55 § 15 74§78 365§139
0.1 0.056 0.027
73§24
105§55
0.014
34% 39% PCS 56% CS 5% other 83% CH 17% RF 0% CM
56% 44% PCS 44 % CS 12% other 75% CH 3% RF 22% CM
0.14 0.73 0.42 0.42 0.52 0.08 0.03
414 Predictors of Survival to Discharge and Ventricular Recovery after VA-ECMO Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock J.A. Fried,1 M. Cevasco,2 L. Witer,2 A. Masoumi,1 D. Brodie,3 J. Griffith,1 V. Topkara,1 K. Clerkin,1 A. Zuver,1 D. Karmpaliotis,1 A. Kirtane,1 H. Takayama,2 M. Yuzefpolskaya,1 Y. Naka,2 P. Colombo,1 K. Takeda,2 and A.R. Garan.2 1Cardiology, Columbia University Medical Center, New York, NY; 2Cardiothoracic Surgery, Columbia University Medical Center, New York, NY; and the 3Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, NY. Purpose: The use of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) following acute myocardial infarction (AMI) with cardiogenic shock (CS) is increasing, but the ability to predict favorable clinical
Abstracts response is limited. We investigated predictors of in hospital mortality and ventricular recovery in patients supported with VA-ECMO for AMI-CS. Methods: We retrospectively reviewed charts of patients with AMI who were supported with VA-ECMO from 2007-2018. Data collected included AMI characteristics and measures of cardiac function. Logistic regression was used to identify predictors of survival to discharge and recovery which was defined as survival to discharge without heart replacement therapy (HRT, durable LVAD or transplant). Results: 137 patients were treated with VA-ECMO for AMI during the study period. Mean cardiac index at implantation in the cohort was 1.82 §0.53 and 26 patients (18.9%) had VA-ECMO placed during active CPR. 43 patients (31.4%) were supported with IABP either before or during VAECMO support; 75 patients (54.7%) were supported with Impella either before or during VA-ECMO support. 30-day survival was 60.6% and 52.6% survived to discharge. Of the 72 patients surviving to discharge, 26 (36.1%) were discharged with HRT and 46 (63.9%) had recovery. In a multivariable analysis including, age, gender, lactate, TIMI 3 flow in culprit artery, and LV ejection fraction, younger age was the only independent predictor of survival to discharge (OR 1.18, p=0.02). Independent predictors of ventricular recovery were presence of TIMI 3 flow in culprit artery (OR 5.45, p=0.03) and residual CAD (OR 0.22, p=0.04, Table). At a median follow-up of 375 days (IQR 112, 959) after discharge, 2/46 (4.3%) patients required HRT. Conclusion: In patients supported with VA-ECMO for AMI-CS, younger age was associated with survival to discharge while markers of successful revascularization were associated with ventricular recovery.
S177 to 30 days was greater for those initiated on complete support within 8 hours (p 0.04) and significantly worse for those implanted at 17-24 hours post onset of CS (p 0.02). Survival to explant (p 0.02) and survival to discharge (p 0.04) were worse in the 17-24 hour group. This was driven primarily by the AMI-CS group. Those with a shock to support time >24 hours had numerically lower survival rates, but did not reach significance, likely due to the small sample size. Conclusion: A shock to support time of less than 8 hours was associated with improved 30 day mortality where as shock to support time of 1724 hours had worse 30 day mortality, survival to explant and survival to discharge.
415 Effect of Time from Cardiogenic Shock to Initiation of Complete Cardiovascular Support on Survival: “Shock to Support Time” A. Scatola,1 A. Singh,1 K. Singh,2 N. Singh,2 and P. Meraj.1 1Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; and the 2New York Institute of Technology, New York, NY. Purpose: The treatment for cardiogenic shock (CS) is moving to earlier utilization of complete mechanical circulatory support. Complete mechanical support can be achieved with venoarterial extracorporeal membrane oxygenation (VA-ECMO), temporary percutaneous left ventricular assist devices [Impella, (Abiomed, Danvers, MA)] and the combination of VAECMO with Impella (ECPELLA). Evidence from the acute myocardial infarction complicated by cardiogenic shock (AMI-CS) population has shown that earlier mechanical support leads to better outcomes and this concept may also hold true for other etiologies. Methods: This prospective observational study (2015-9/2018) looked at the time from onset of refractory CS to time of full circulatory support with either VA-ECMO or ECPELLA. Demographics, indication for support, and hemodynamic data were collected for all patients. Etiologies for cardiogenic shock included AMI-CS, cardiac arrest and nonAMI shock. Time to support was grouped as 0-8 hours, 9-16 hours, 1724 hours and >24 hours. The primary outcome was mortality at 30 days. Secondary outcomes included survival to device explant and survival to discharge. Results: A total of 52 patients were identified; 32 had VA-ECMO and 20 had ECPELLA. Both groups had similar baseline characteristics. Survival
416 Risk and Causes of 30-Day Readmissions Following Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock N. Tashtish,1 S. Al-Kindi,2 M. Karnib,1 C. Di Felice,3 E. Zanath,4 G. Oliveira,2 F. Lytle,4 and C. Elamm.2 1Internal Medicine, University Hosptials Cleveland Medical Center, Cleveland, OH; 2Cardiovascular Medicine, University Hosptials Cleveland Medical Center, Cleveland, OH; 3 Pulmonary and Critical Care, University Hosptials Cleveland Medical Center, Cleveland, OH; and the 4Department of Anesthesia, University Hosptials Cleveland Medical Center, Cleveland, OH. Purpose: Cardiogenic shock (CS) is associated with significant mortality, morbidity and healthcare costs. Extracorporeal membrane oxygenation (ECMO) is increasingly used in CS. Inpatient mortality is high, but readmission risk in survivors is not well studied. We conducted our study to identify risk and causes of 30-day readmission following ECMO. Methods: Using the 2016 Healthcare Cost and Utilization Project National Readmission Database, we studied the incidence and causes of 30-day readmissions following ECMO support for CS (January to November 2016). Patients < 18 years of age were excluded. CS, ECMO, and comorbidities were identified using their respective ICD codes. Logistic regression models were used to explore risk factors for 30-day readmissions. Results: Out of 62,302 patients admitted for CS, 1490 (2.4%) were supported with ECMO. Median time from admission to ECMO placement
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
and alternative outflow graft locations. Patients were implanted directly from ECMO in 17%. Results: Compared to patients implanted with an HVAD without baseline ECMO, those implanted directly from ECMO experienced a higher rate of bleeding events (0.30 vs. 0.11 events per patient year (EPPY), p value = 0.02, respectively), more renal dysfunction (0.19 vs. 0.05 EPPY, p value = 0.03) and a trend toward few cardiac arrythmias (0.19 vs. 0.07 EPPY, p value = 0.08). Overall survival at one year post implant was 81% in the non-ECMO thoracotomy group, compared to 56% in the group implanted directly from ECMO (p value = 0.0003). Conclusion: The analysis of real world use of the HVAD implanted using a thoracotomy approach demonstrates that there is significantly worse survival and adverse event profile in patients undergoing implants off ECMO. However, these results do not appear to be worse than previous reports of LVAD implants off ECMO via a sternotomy approach.
412 Mid Term Survival after VA ECMO Weaning A. Vincentelli,1 N. Rousse,1 V. Loobuyck,1 M. Moussa,2 A. Mugnier,1 J. Soquet,1 E. Robin,2 F. Juthier,1 C. Goeminne,1 and C. Banfi.1 1Cardiac Surgery, Centre Hospitalier Universitaire Regional de Lille, Lille, France; and the 2Cardiac Surgery, Anesthesiology, Centre Hospitalier Universitaire Regional de Lille, Lille, France. Purpose: The aimed of this study was to evaluate the outcome of the patients successfully weaned from ECMO after cardiac recovery. Methods: From January 2008 to January 2018, 384 patients were supported with VA ECMO for cardiogenic shock in our institution. 47.1% patients (n=181) died during support. 40.9% patients were weaned from VA-ECMO (n=157), 5.7% (n=22 were supported with a LVAD or a TAH and 6.3%patients (n=4) received a heart transplant. We prospectively followed the patients weaned from ECMO by periodic visit at our center. We analyzed survival, causes of early and late deaths and predictors for death for this population. Results: 157 patients, median age 52 years (1st and 3rd quart. 39-62), were successfully weaned from VA ECMO after a median time of 7 days of support (1st and 3rd quart. 4-10 days). Main etiologies of shock were post cardiotomy (n=57, 36.3%), acute myocardial infarction (n=39, 24.8%), pulmonary embolism (n=11, 7.0%), myocarditis (n=6, 3.8%), and acute end stage heart failure (n=6, 3.8%). During a mean follow up of 1.9 years (max 10 years), 137 patients were discharged home. Early deaths (< 3 months) were due to: septic shock (n=4), brain death (n = 4), multiple organ failure (n= 8), therapeutic limitations (n= 4). Late deaths (> 2 years from ECMO weaning) were due to septic shock (n=4), heart graft failure (n=1), unknown (n=1). Three patients underwent HTx, 2 others patients are still waiting for a HTx,. Overall one-month, 6- month and 3-years survival were respectively of 93.4 (IC: 87.7-96.5); 83.4% (IC: 75.3- 89.0) and 76.5% (IC: 65.1-84.6). By multivariate Cox analysis, ECMO duration (HR= 1.15, p=0.0002), stroke during ECMO course (HR =3.85, p=0.0015), age (HR=1.06, p=0.0008), and post cardiotomy shock (HR =3.62, p=0.0124) were independent risk factor for death. Conclusion: In our ten-year experience, patients could be successfully weaned from ECMO after a refractory shock. Most of them had a satisfactory outcome and could be discharged home. Older age, a longer duration of support, stroke and post cardiotomy shock were associated with poor outcome. Further studies are needed to evaluate the risk of recurrence of heart failure and a close follow up of those patients is mandatory.
413 Does Transport Time or Distance from Hospital Affect Survival in Extracorporeal Membrane Oxygenation (ECMO) Patients? J.S. Nelson, A. Eisenbeiss, E. Stauder, K. Graham, R. Alharethi, W. Caine, H. Smith, B. Reid, M. McCulloch, B. Rasmusson, V. Hebl and B. Kfoury. Intermountain Medical Center, Murray, UT. Purpose: Many hospitals in the United States are limited in their capabilities to treat advanced heart disease. This limitation results in patients needing to be transferred to a facility with the capacity to provide higher levels of care when ECMO support has been initiated. In this study we aim to look at whether transport time or distance impacts survival rate of implanted ECMO patients. Methods: The Artificial Heart Program’s database at Intermountain Medical Center was queried from June 2007 - 2017 for patients transported to the Intermountain facility on ECMO. Patients were stratified into two groups. Group 1: those who survived to discharge and Group 2: those who expired before discharge. Seven parameters were evaluated for significance: age, distance transported, time from initial request to arrival, transport time, whether chest compressions were performed, indication for support and type of support. A two-sample t-test was used to determine significance. Results: 50 patients met study inclusion criteria; 29 were male and 21 were female. The average age for Group 1 was 49§13 years compared to Group 2, 55 § 15 years. The average transport distance and time was 125§118 miles & 73§24 minutes for Group 1 vs 74§78 miles & 105§55 minutes for Group 2. The time from life flight request was 293§85 minutes vs 365§139 minutes for Group 1 vs Group 2. The majority of patients were implanted with CARDIOHELP (CH) (p=0.52). Additional preliminary factors such as indications for support and whether patient received chest compressions are summarized below. Conclusion: Our observations indicate that increased transport time correlates with a lower survival rate. Whereas we found no significance in the distance the patient traveled. The average distance for Group 1 was 40% farther then Group 2. This study suggests that decreasing the time from ECMO request to transportation arrival and decreasing the time of transport could lead to improved survival of ECMO patients transferred between hospitals.
Parameters Age(years) Distance(miles) Time from initial request (minutes) Transport time from bed to IMC (minutes) Compressions prior to ECMO Indication for support
Type of support
Survived (n=18)
Expired (n=32)
P-value
49§13 125§118 293§85
55 § 15 74§78 365§139
0.1 0.056 0.027
73§24
105§55
0.014
34% 39% PCS 56% CS 5% other 83% CH 17% RF 0% CM
56% 44% PCS 44 % CS 12% other 75% CH 3% RF 22% CM
0.14 0.73 0.42 0.42 0.52 0.08 0.03
414 Predictors of Survival to Discharge and Ventricular Recovery after VA-ECMO Support for Acute Myocardial Infarction Complicated by Cardiogenic Shock J.A. Fried,1 M. Cevasco,2 L. Witer,2 A. Masoumi,1 D. Brodie,3 J. Griffith,1 V. Topkara,1 K. Clerkin,1 A. Zuver,1 D. Karmpaliotis,1 A. Kirtane,1 H. Takayama,2 M. Yuzefpolskaya,1 Y. Naka,2 P. Colombo,1 K. Takeda,2 and A.R. Garan.2 1Cardiology, Columbia University Medical Center, New York, NY; 2Cardiothoracic Surgery, Columbia University Medical Center, New York, NY; and the 3Pulmonary and Critical Care Medicine, Columbia University Medical Center, New York, NY. Purpose: The use of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) following acute myocardial infarction (AMI) with cardiogenic shock (CS) is increasing, but the ability to predict favorable clinical
Abstracts response is limited. We investigated predictors of in hospital mortality and ventricular recovery in patients supported with VA-ECMO for AMI-CS. Methods: We retrospectively reviewed charts of patients with AMI who were supported with VA-ECMO from 2007-2018. Data collected included AMI characteristics and measures of cardiac function. Logistic regression was used to identify predictors of survival to discharge and recovery which was defined as survival to discharge without heart replacement therapy (HRT, durable LVAD or transplant). Results: 137 patients were treated with VA-ECMO for AMI during the study period. Mean cardiac index at implantation in the cohort was 1.82 §0.53 and 26 patients (18.9%) had VA-ECMO placed during active CPR. 43 patients (31.4%) were supported with IABP either before or during VAECMO support; 75 patients (54.7%) were supported with Impella either before or during VA-ECMO support. 30-day survival was 60.6% and 52.6% survived to discharge. Of the 72 patients surviving to discharge, 26 (36.1%) were discharged with HRT and 46 (63.9%) had recovery. In a multivariable analysis including, age, gender, lactate, TIMI 3 flow in culprit artery, and LV ejection fraction, younger age was the only independent predictor of survival to discharge (OR 1.18, p=0.02). Independent predictors of ventricular recovery were presence of TIMI 3 flow in culprit artery (OR 5.45, p=0.03) and residual CAD (OR 0.22, p=0.04, Table). At a median follow-up of 375 days (IQR 112, 959) after discharge, 2/46 (4.3%) patients required HRT. Conclusion: In patients supported with VA-ECMO for AMI-CS, younger age was associated with survival to discharge while markers of successful revascularization were associated with ventricular recovery.
S177 to 30 days was greater for those initiated on complete support within 8 hours (p 0.04) and significantly worse for those implanted at 17-24 hours post onset of CS (p 0.02). Survival to explant (p 0.02) and survival to discharge (p 0.04) were worse in the 17-24 hour group. This was driven primarily by the AMI-CS group. Those with a shock to support time >24 hours had numerically lower survival rates, but did not reach significance, likely due to the small sample size. Conclusion: A shock to support time of less than 8 hours was associated with improved 30 day mortality where as shock to support time of 1724 hours had worse 30 day mortality, survival to explant and survival to discharge.
415 Effect of Time from Cardiogenic Shock to Initiation of Complete Cardiovascular Support on Survival: “Shock to Support Time” A. Scatola,1 A. Singh,1 K. Singh,2 N. Singh,2 and P. Meraj.1 1Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY; and the 2New York Institute of Technology, New York, NY. Purpose: The treatment for cardiogenic shock (CS) is moving to earlier utilization of complete mechanical circulatory support. Complete mechanical support can be achieved with venoarterial extracorporeal membrane oxygenation (VA-ECMO), temporary percutaneous left ventricular assist devices [Impella, (Abiomed, Danvers, MA)] and the combination of VAECMO with Impella (ECPELLA). Evidence from the acute myocardial infarction complicated by cardiogenic shock (AMI-CS) population has shown that earlier mechanical support leads to better outcomes and this concept may also hold true for other etiologies. Methods: This prospective observational study (2015-9/2018) looked at the time from onset of refractory CS to time of full circulatory support with either VA-ECMO or ECPELLA. Demographics, indication for support, and hemodynamic data were collected for all patients. Etiologies for cardiogenic shock included AMI-CS, cardiac arrest and nonAMI shock. Time to support was grouped as 0-8 hours, 9-16 hours, 1724 hours and >24 hours. The primary outcome was mortality at 30 days. Secondary outcomes included survival to device explant and survival to discharge. Results: A total of 52 patients were identified; 32 had VA-ECMO and 20 had ECPELLA. Both groups had similar baseline characteristics. Survival
416 Risk and Causes of 30-Day Readmissions Following Extracorporeal Membrane Oxygenation Support for Cardiogenic Shock N. Tashtish,1 S. Al-Kindi,2 M. Karnib,1 C. Di Felice,3 E. Zanath,4 G. Oliveira,2 F. Lytle,4 and C. Elamm.2 1Internal Medicine, University Hosptials Cleveland Medical Center, Cleveland, OH; 2Cardiovascular Medicine, University Hosptials Cleveland Medical Center, Cleveland, OH; 3 Pulmonary and Critical Care, University Hosptials Cleveland Medical Center, Cleveland, OH; and the 4Department of Anesthesia, University Hosptials Cleveland Medical Center, Cleveland, OH. Purpose: Cardiogenic shock (CS) is associated with significant mortality, morbidity and healthcare costs. Extracorporeal membrane oxygenation (ECMO) is increasingly used in CS. Inpatient mortality is high, but readmission risk in survivors is not well studied. We conducted our study to identify risk and causes of 30-day readmission following ECMO. Methods: Using the 2016 Healthcare Cost and Utilization Project National Readmission Database, we studied the incidence and causes of 30-day readmissions following ECMO support for CS (January to November 2016). Patients < 18 years of age were excluded. CS, ECMO, and comorbidities were identified using their respective ICD codes. Logistic regression models were used to explore risk factors for 30-day readmissions. Results: Out of 62,302 patients admitted for CS, 1490 (2.4%) were supported with ECMO. Median time from admission to ECMO placement