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Published on: January 17, 2025
Extracorporeal membrane oxygenation for infant postcardiotomy support: significance of shunt management
J J Jaggers1, J M Forbess, A S Shah
1Pediatric Cardiovascular Program, Duke University Medical Center, Durham, North Carolina 27710, USA. jagge003@mc.duke.edu
Insights
Post-cardiac surgery failure in children can be managed with extracorporeal membrane oxygenation (ECMO). For single-ventricle patients with aorto-pulmonary shunts, leaving the shunt open during ECMO support significantly improves survival rates.
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery
- Critical Care Medicine
Background:
- Post-cardiotomy cardiac failure is a risk in infants and children after complex congenital heart defect repair.
- Extracorporeal membrane oxygenation (ECMO) is the primary method for temporary circulatory support.
- Managing ECMO in patients with single-ventricle physiology and aorto-pulmonary shunts presents unique challenges.
Purpose of the Study:
- To review the use of postcardiotomy mechanical circulatory support in children.
- To specifically analyze outcomes in patients with single-ventricle palliation.
- To identify factors influencing survival in pediatric patients requiring ECMO support.
Main Methods:
- Retrospective review of 35 pediatric patients (1-820 days old) requiring ECMO after congenital cardiac repair (Feb 1994 - Apr 1999).
- Analysis included 25 patients with two-ventricle repairs and 10 with single-ventricle palliation.
- Key parameters studied were shunt management strategies, pre-support cardiac arrest, and timing of support initiation.
Main Results:
- Overall hospital survival was 61% (21 of 35 patients).
- Survival rates were similar whether ECMO was initiated in the OR or after separation from cardiopulmonary bypass (60% survival).
- In shunt-dependent pulmonary circulation, survival was significantly improved with an open aorto-pulmonary shunt (4 of 5) versus an occluded shunt (0 of 4, p=0.048).
Conclusions:
- Readily available postcardiotomy support is crucial for managing complex pediatric congenital heart disease.
- Satisfactory survival rates are achievable with rational and prompt implementation of support.
- Maintaining an open aorto-pulmonary shunt during ECMO support markedly improves outcomes in single-ventricle physiology patients.
Background:
After repair of complex congenital heart defects in infants and children, postcardiotomy cardiac failure requiring temporary circulatory support can occur. This is usually accomplished with the use of extracorporeal membrane oxygenation (ECMO). ECMO management of patients with single-ventricle physiology and aorto-pulmonary shunts can be particularly challenging. We retrospectively reviewed our experience with postcardiotomy support with particular attention to those children with single-ventricle palliation.
Methods:
Thirty-five consecutive children (age 1 to 820 days, median 19 days) out of 1,020 patients (3.4%) required mechanical support (ECMO) after repair of congenital cardiac lesions from February 1994 to April 1999. Twenty-five patients underwent two ventricle repairs and 10 patients had single-ventricle palliation. Various parameters analyzed included strategies of shunt management, presence of presupport cardiac arrest, and timing of support initiation.
Results:
Overall hospital survival for these 35 patients was 61%. There were four additional late deaths. Hospital survival was the same for those patients in whom support was initiated for failure to wean from cardiopulmonary bypass in the operating room versus those patients in whom support was initiated after successful separation from cardiopulmonary bypass (6 of 10 vs 15 of 25 or 60% survival). In those patients with shunt-dependent pulmonary circulation, survival was significantly improved in those patients in which the aorto-pulmonary shunt was left open (4 of 5 with open shunt vs 0 of 4 with occluded shunt (p = 0.048).
Conclusions:
The ability to readily implement postcardiotomy support is vital to the management of children with complex congenital cardiac disease. Overall survival can be quite satisfactory if support is employed in a rational and expedient manner. In patients with single-ventricle physiology and aorto-pulmonary shunts, leaving the shunt open during the period of support can result in markedly improved outcomes.
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