Temporary mechanical support in fulminant myocarditis: prognostic factors and clinical implications from the FULLMOON study

Intensive Care Medicine | Published: 12 January 2026

Background

Temporary mechanical circulatory support (t-MCS) is increasingly used in fulminant myocarditis (FM), yet long-term outcomes and risk factors remain poorly defined.

Methods

From the FULLMOON international cohort (419 adults with suspected FM across 36 centers in 15 countries), 295 patients treated with venoarterial extracorporeal membrane oxygenation (V-A ECMO) and/or Impella were analyzed. The primary endpoint was mortality at 1 year, heart transplantation (HTx), or left-ventricular assist device (LVAD). Multivariate Cox regression identified predictors of adverse outcomes. A propensity score-weighted analysis assessed outcomes based on timing of endomyocardial biopsy (EMB): early (≤ 2 days), delayed (> 2 days), or none.

Results

The median age was 39 years (IQR 28–60), and 55% were female. Myocarditis was confirmed in 204 (69%) of the patients via histology or cardiac MRI. Histological data were available for 151 (51%) of the cohort. One-year mortality was 36%, while 44% died or had an HTx or LVAD. Predictors of worse outcomes were giant cell myocarditis, older age, cardiac arrest at ECMO initiation, and delayed EMB. Delayed EMB was consistently associated with higher mortality, HTx, or LVAD compared to early (HR = 1.55; 95% CI 1.23–1.96; p < 0.01) or no EMB (HR = 1.59; 95% CI 1.26–2.01; p < 0.01). However, event-free survival did not differ significantly between early EMB and no EMB (HR = 1.03; 95% CI 0.80–1.32; p = 0.85).

Conclusions

Despite a relatively young cohort, FM requiring t-MCS is associated with a high 1-year mortality rate. Timely recognition and early referral to specialized ECMO centers before cardiac arrest are critical.

 

Tidal volume and mortality during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a multicenter observational cohort study

Annals of Intensive Care volume 15, Article number: 151 (2025) Published: 06 October 2025

Background

Approximately half of the patients with acute respiratory distress syndrome (ARDS) receiving extracorporeal membrane oxygenation (ECMO) remain ECMO-dependent beyond 14 days after ECMO initiation. The identification of factors associated with mortality during an ECMO run may update prognostic assessment and focus clinical interventions.

Methods

In this observational study, data from 1137 patients with COVID-19 ARDS receiving ECMO support in 29 German centers between January 1st 2020 and July 31st 2021 were analyzed. Multivariable stepwise logistic regression analyses were performed to build survival prediction models with day-by-day data during the first 14 days of an ECMO run. The primary endpoint was all-cause mortality in the intensive care unit.

Results

Mortality in this cohort was high (75%). Patients who remained ECMO-dependent on day 14 of their ECMO run showed comparable mortality to all patients receiving ECMO support on day 1. Yet, factors associated with mortality changed during the first 14 days of ECMO support. On day 1 of ECMO support, only patient age and lactate remained in the final mortality prediction model. On day 14 of an ECMO run, tidal volume was independently associated with mortality (adjusted Odds Ratio 0.693 (95%CI 0.564–0.851), p < 0.001 for 1 mL/kg increase in tidal volume per predicted body weight). The adjusted mortality for patients with a tidal volume below 2 mL/kg on day 14 of their ECMO run was above 80% (lower limit of the 95%CI interval). Higher tidal volume was mainly based on higher respiratory system compliance. Yet, the benefit of higher compliance was not observed in some patients who were still ventilated with very low driving pressures despite remaining ECMO-dependent on day 14 of ECMO support.

Conclusions

Mortality predictors change during the course of an ECMO run. In a cohort with high mortality, on day 14 of ECMO support for ARDS, tidal volume may be an independent predictor of mortality. Further analyses on ventilation strategies in patients who remain ECMO-dependent are needed.

 

Development and external validation of a machine learning model for brain injury in pediatric patients on extracorporeal membrane oxygenation

Critical Care 29, Article number: 17 (2025)

Published: 09 January 2025

Background

Patients supported by extracorporeal membrane oxygenation (ECMO) are at a high risk of brain injury, contributing to significant morbidity and mortality. This study aimed to employ machine learning (ML) techniques to predict brain injury in pediatric patients ECMO and identify key variables for future research.

Methods

Data from pediatric patients undergoing ECMO were collected from the Chinese Society of Extracorporeal Life Support (CSECLS) registry database and local hospitals. Ten ML methods, including random forest, support vector machine, decision tree classifier, gradient boosting machine, extreme gradient boosting, light gradient boosting machine, Naive Bayes, neural networks, a generalized linear model, and AdaBoost, were employed to develop and validate the optimal predictive model based on accuracy and area under the curve (AUC). Patients were divided into retrospective cohort for model development and internal validation, and one cohort for external validation.

Results

A total of 1,633 patients supported by ECMO were included in the model development, of whom 181 experienced brain injury. In the external validation cohort, 30 of the 154 patients experienced brain injury. Fifteen features were selected for the model construction. Among the ML models tested, the random forest model achieved the best performance, with an AUC of 0.912 for internal validation and 0.807 for external validation.

Conclusion

The Random Forest model based on machine learning demonstrates high accuracy and robustness in predicting brain injury in pediatric patients supported by ECMO, with strong generalization capabilities and promising clinical applicability.

 

Diaphragm thickness modifications and associated factors during VA-ECMO for a cardiogenic shock: a cohort study

 

by Pierre-Henri Moury, Alexandre Béhouche, Sébastien Bailly, Zoé Durand, Géraldine Dessertaine, Angelina Pollet, Samir Jaber, Samuel Verges and Pierre Albaladejo 

 

Annals of Intensive Care volume 14, Article number: 38 (2024) Published: 08 March 2024

 

Background

The incidence, causes and impact of diaphragm thickness evolution in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock are unknown.

Our study investigates its evolution during the first week of VA-ECMO and its relationship with sweep gas flow settings.

Methods

We conducted a prospective monocentric observational study in a 12-bed ICU in France, enrolling patients on the day of the VA-ECMO implantation. The diaphragm thickness and the diaphragm thickening fraction (as index of contractile activity, dTF; dTF < 20% defined a low contractile activity) were daily measured for one week using ultrasound. Factors associated with diaphragm thickness evolution (categorized as increased, stable, or atrophic based on > 10% modification from baseline to the last measurement), early extubation role (< day4), and patients outcome at 60 days were investigated. Changes in diaphragm thickness, the primary endpoint, was analysed using a mixed-effect linear model (MLM).

Results

Of the 29 included patients, seven (23%) presented diaphragm atrophy, 18 remained stable (60%) and 4 exhibited an increase (17%). None of the 13 early-extubated patients experienced diaphragm atrophy, while 7 (46%) presented a decrease when extubated later (p-value = 0.008). Diaphragm thickness changes were not associated with the dTF (p-value = 0.13) but with sweep gas flow (Beta = − 3; Confidence Interval at 95% (CI) [− 4.8; − 1.2]. p-value = 0.001) and pH (Beta = − 2; CI [− 2.9; − 1]. p-value < 0.001) in MLM. The dTF remained low (< 20%) in 20 patients (69%) at the study’s end and was associated with sweep gas flow evolution in MLM (Beta = − 2.8; 95% CI [− 5.2; − 0.5], p-value = 0.017). Odds ratio of death at 60 days in case of diaphragm atrophy by day 7 was 8.50 ([1.4–74], p = 0.029).

Conclusion

In our study, diaphragm thickness evolution was frequent and not associated with the diaphragm thickening fraction. Diaphragm was preserved from atrophy in case of early extubation with ongoing VA-ECMO assistance. Metabolic disorders resulting from organ failures and sweep gas flow were linked with diaphragm thickness evolution. Preserved diaphragm thickness in VA-ECMO survivors emphasizes the importance of diaphragm-protective strategies, including meticulous sweep gas flow titration.

 Expert consensus statement on venovenous extracorporeal membrane oxygenation ECMO for COVID-19 severe ARDS: an international Delphi study

by Ahmed A. Rabie, Alyaa Elhazmi, Mohamed H. Azzam, Akram Abdelbary, Ahmed Labib, Alain Combes, Bishoy Zakhary, Graeme MacLaren, Ryan P. Barbaro, Giles J. Peek, Marta Velia Antonini, Kiran Shekar, Abdulrahman Al‐Fares, Pranay Oza, Yatin Mehta, Huda Alfoudri

Annals of Intensive Care volume 13, Article number: 36 (2023)

 

Background

The high-quality evidence on managing COVID-19 patients requiring extracorporeal membrane oxygenation (ECMO) support is insufficient. Furthermore, there is little consensus on allocating ECMO resources when scarce. The paucity of evidence and the need for guidance on controversial topics required an international expert consensus statement to understand the role of ECMO in COVID-19 better. Twenty-two international ECMO experts worldwide work together to interpret the most recent findings of the evolving published research, statement formulation, and voting to achieve consensus.

Objectives

To guide the next generation of ECMO practitioners during future pandemics on tackling controversial topics pertaining to using ECMO for patients with COVID-19-related severe ARDS.

Methods

The scientific committee was assembled of five chairpersons with more than 5 years of ECMO experience and a critical care background. Their roles were modifying and restructuring the panel’s questions and, assisting with statement formulation in addition to expert composition and literature review. Experts are identified based on their clinical experience with ECMO (minimum of 5 years) and previous academic activity on a global scale, with a focus on diversity in gender, geography, area of expertise, and level of seniority. We used the modified Delphi technique rounds and the nominal group technique (NGT) through three face-to-face meetings and the voting on the statement was conducted anonymously. The entire process was planned to be carried out in five phases: identifying the gap of knowledge, validation, statement formulation, voting, and drafting, respectively.

Results

In phase I, the scientific committee obtained 52 questions on controversial topics in ECMO for COVID-19, further reviewed for duplication and redundancy in phase II, resulting in nine domains with 32 questions with a validation rate exceeding 75% (Fig. 1). In phase III, 25 questions were used to formulate 14 statements, and six questions achieved no consensus on the statements. In phase IV, two voting rounds resulted in 14 statements that reached a consensus are included in four domains which are: patient selection, ECMO clinical management, operational and logistics management, and ethics.

Conclusion

Three years after the onset of COVID-19, our understanding of the role of ECMO has evolved. However, it is incomplete. Tota14 statements achieved consensus; included in four domains discussing patient selection, clinical ECMO management, operational and logistic ECMO management and ethics to guide next-generation ECMO providers during future pandemic situations.

 

Early hyperoxia and 28-day mortality in patients on venoarterial ECMO support for refractory cardiogenic shock: a bicenter retrospective propensity score-weighted analysis

 

by Mouhamed Djahoum Moussa, Christophe Beyls, Antoine Lamer, Stefan Roksic, Francis Juthier, Guillaume Leroy, Vincent Petitgand, Natacha Rousse, Christophe Decoene, Céline Dupré, Thierry Caus, Pierre Huette, Mathieu Guilbart, Pierre-Grégoire Guinot, Patricia Besserve, Yazine Mahjoub

 

Critical Care volume 26, Article number: 257 (2022) 

 

Background

The mortality rate for a patient with a refractory cardiogenic shock on venoarterial (VA) extracorporeal membrane oxygenation (ECMO) remains high, and hyperoxia might worsen this prognosis. The objective of the present study was to evaluate the association between hyperoxia and 28-day mortality in this setting.

Methods

We conducted a retrospective bicenter study in two French academic centers. The study population comprised adult patients admitted for refractory cardiogenic shock. The following arterial partial pressure of oxygen (PaO2) variables were recorded for 48 h following admission: the absolute peak PaO2 (the single highest value measured during the 48 h), the mean daily peak PaO2 (the mean of each day’s peak values), the overall mean PaO2 (the mean of all values over 48 h), and the severity of hyperoxia (mild: PaO2 < 200 mmHg, moderate: PaO2 = 200–299 mmHg, severe: PaO2 ≥ 300 mmHg). The main outcome was the 28-day all-cause mortality. Inverse probability weighting (IPW) derived from propensity scores was used to reduce imbalances in baseline characteristics.

Results

From January 2013 to January 2020, 430 patients were included and assessed. The 28-day mortality rate was 43%. The mean daily peak, absolute peak, and overall mean PaO2 values were significantly higher in non-survivors than in survivors. In a multivariate logistic regression analysis, the mean daily peak PaO2, absolute peak PaO2, and overall mean PaO2 were independent predictors of 28-day mortality (adjusted odds ratio [95% confidence interval per 10 mmHg increment: 2.65 [1.79–6.07], 2.36 [1.67–4.82], and 2.85 [1.12–7.37], respectively). After IPW, high level of oxygen remained significantly associated with 28-day mortality (OR = 1.41 [1.01–2.08]; P = 0.041).

Conclusions

High oxygen levels were associated with 28-day mortality in patients on VA-ECMO support for refractory cardiogenic shock. Our results confirm the need for large randomized controlled trials on this topic.

 

Bleeding and thrombotic events in patients with severe COVID-19 supported with extracorporeal membrane oxygenation: a nationwide cohort study

 

Intensive Care Medicine volume 48, pages 1039–1052 (2022) Published: 13 July 2022

 

Purpose

To describe bleeding and thrombotic events and their risk factors in patients receiving extracorporeal membrane oxygenation (ECMO) for severe 

coronavirus disease 2019

 (COVID-19) and to evaluate their impact on in-hospital mortality.

Methods

The ECMOSARS registry included COVID-19 patients supported by ECMO in France. We analyzed all patients included up to March 31, 2022 without missing data regarding bleeding and thrombotic events. The association of bleeding and thrombotic events with in-hospital mortality and pre-ECMO variables was assessed using multivariable logistic regression models.

Results

Among 620 patients supported by ECMO, 29% had only bleeding events, 16% only thrombotic events and 20% both bleeding and thrombosis. Cannulation site (18% of patients), ear nose and throat (12%), pulmonary bleeding (9%) and intracranial hemorrhage (8%) were the most frequent bleeding types. Device-related thrombosis and pulmonary embolism/thrombosis accounted for most of thrombotic events. In-hospital mortality was 55.7%. Bleeding events were associated with in-hospital mortality (adjusted odds ratio (adjOR) = 2.91[1.94–4.4]) but not thrombotic events (adjOR = 1.02[0.68–1.53]). Intracranial hemorrhage was strongly associated with in-hospital mortality (adjOR = 13.5[4.4–41.5]). Ventilation duration before ECMO ≥ 7 days and length of ECMO support were associated with bleeding. Thrombosis-associated factors were fibrinogen ≥ 6 g/L and length of ECMO support.

Conclusions

In a nationwide cohort of COVID-19 patients supported by ECMO, bleeding incidence was high and associated with mortality. Intracranial hemorrhage incidence was higher than reported for non-COVID patients and carried the highest risk of death. Thrombotic events were less frequent and not associated with mortality. Length of ECMO support was associated with a higher risk of both bleeding and thrombosis, supporting the development of strategies to minimize ECMO duration.