Background:

1. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? C. Amarelli, Marco Montibello, Danilo Casale, Luigi Verniero Antonella Capasso, Nicola Galdieri, Pasquale Santè, Ciro Maiello Monaldi Hospital -Azienda Ospedaliera dei Colli - Naples (IT)

2. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? Background: • ECMO is an effective strategy to mantain an optimal peripheral perfusion in patients affected from acute heart failure.

3. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? Background: • Coagulative disorders, Ventilator Associated Pneumonia (VAP) and infectious complications are frequent and commonly are the principal cause of MOF and death in such patients.

4. The mostdreadfulcomplicationofHeparinis HIT (HeparinInducedThrombocitopenia)

5. Course of Platelet Count in HIT

6. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? Background: • Bivaluridin as been advocate in ECMO to reduce the incidence of HIT, while fast-track may be used to reduce VAP in this setting.

7. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? In a tertiary care center for Heart Transplantation and Cardiovascular Surgery during the last two years of experience 9 of 21 patients implanted with an ECMO were treated with bivaluridin aiming to reduce coagulative disorders. 1 patient 8 patients

8. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? Levitronix® Study Aim: To Assess the impact of bivaluridin and fast extubation in a small monocentric pilot experience on ECMO.

9. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? All patients but one were kept extubate immediately after implantation. Weaning from ECMO was always attempted in a policy of bridge to decision and was performed according to the criteria of Aissaoui et al. Patients who tolerated a full ECMO weaning trial and had aortic VTI C10 cm, LVEF 20–25%, and TDSaC 6 cm/s at minimal ECMO flow.

10. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? • The indication for ECMO implantation were: • Early Graft Failure (EGF) in 2 cases • Post-cardiotomy failure in 2 cases • Acute Rejection in 1 case • Complications of AMI in 4 cases

11. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? Results • ECMO was successful in warrant optimal perfusion in all cases. • HIT nor pneumonia were never observed in this small series. • Two cases of pulmonary edema were managed with noninvasive CPAP ventilation with helmet. One ECMO (postcardiotomy) was futile due to Cerebral Anoxia.

12. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? . One patient underwent successful heart transplantation and 2 patient underwent Interventricular Septum Closure. Hospital mortality however was 45%. In 2 cases (50%) mortality was due to poor residual myocardial function despite acceptable myocardial function according to Assaoui Criteria.

13. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? Results

14. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy?

15. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? A novel approach in the management of ECMO based on bivaluridin and fast extubation reduce the incidence of coagulative and infectious complications, although hospital mortality remain still high due to the poor preoperative conditions.

16. ECMO with bivaluridin in extubated patient: the "Holy Grail" of ECMO or only a fashionable policy? Today the bridge to recovery is the principal aim of ECMO implantation at our istitution and the results strictly depend from the underlying disease. A careful echocardiographic evaluation (and probably also Fine Needle byopsies of the heart) and more effective algorithms to achieve a stable weaning from ECMO are necessary to reduce hospital mortality.