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Extracorporeal life support after staged palliation of a functional single ventricle: subsequent morbidity and
Aparna Hoskote1, Desmond Bohn, Colleen Gruenwald
1Department of Critical Care Medicine, The Hospital for Sick Children and University of Toronto, Toronto, Canada.
Insights
Extracorporeal life support (ELS) in infants with single ventricle physiology shows encouraging survival to decannulation. However, multiorgan failure and infection impact survival to hospital discharge.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- Infants with functional single ventricle (FSV) physiology often require advanced circulatory support.
- Postoperative extracorporeal life support (ELS) is a critical intervention for these high-risk patients.
Purpose of the Study:
- To review the outcomes of infants with FSV who received postoperative ELS.
- To identify risk factors associated with mortality in this population.
Main Methods:
- Retrospective review of infants with FSV receiving postoperative ELS between January 1997 and May 2003.
- Analysis of operative procedures, indications for ELS, and patient demographics.
- Evaluation of survival rates, intensive care unit (ICU) stay, and risk factors for non-survival.
Main Results:
- Twenty-five infants received ELS, with 18 undergoing the Norwood stage 1 procedure.
- Indications included cardiac arrest (56%) and low cardiac output (44%).
- Survival to decannulation was 76%, with 44% survival to hospital discharge. Significant risk factors for non-survival included arrhythmia, renal failure, Candida sepsis, and multiorgan failure.
Conclusions:
- While survival to decannulation is promising, multiorgan failure and invasive infections significantly reduce survival to hospital discharge.
- Early initiation of ELS before cardiac arrest may improve outcomes.
- Ventricular assist device (VAD) support alone or conversion from extracorporeal membrane oxygenation (ECMO) to VAD was utilized in a subset of patients.
Objective:
We sought to review the outcome of infants with a functional single ventricle receiving postoperative extracorporeal life support.
Methods:
We reviewed all patients with a functional single ventricle receiving postoperative extracorporeal life support between January 1997 and May 2003.
Results:
We supported 25 infants (age range, 2-139 days; median age, 15 days; weight range, 1.9-5.9 kg; median weight, 3.4 kg) with extracorporeal life support. Operative procedures were Norwood stage 1 procedure in 18 patients, modified Blalock-Taussig shunt in 4 patients, bidirectional superior cavopulmonary shunt in 2 patients, and pulmonary vein repair in 1 patient. Indications for extracorporeal life support included cardiac arrest (14/25) and low cardiac output state (11/25). Extracorporeal membrane oxygenation was initiated in 19 patients, with conversion to a ventricular assist device in 7 patients. Ventricular assist device alone was initiated in 6 patients. Survival to decannulation was 76%, with 5 late deaths from multiorgan failure and 56% intensive care unit survival. Survival to hospital discharge was 44%. On univariate analysis, the presence of arrhythmia before extracorporeal life support (P = .005), renal failure (P = .0007), Candida species-induced sepsis (P = .026), and multiorgan failure (P = .0009) were significant risk factors in the nonsurvivors. Median hospital stay was 43.5 days (range, 6-181 days) for the whole group and 93 days (range, 36-181 days) for survivors. Eight patients completed next stage palliation.
Conclusions:
Twenty percent of patients were supported with a ventricular assist device alone, with 50% conversion to a ventricular assist device from extracorporeal membrane oxygenation. Survival to decannulation was encouraging. Multiorgan failure and risk of invasive infection in the post-extracorporeal membrane oxygenation period mitigate against survival to hospital discharge. Use of extracorporeal life support before cardiac arrest might reduce attrition between decannulation and hospital discharge.
