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Extracorporeal membrane oxygenation support after the Fontan operation
Kelly L Rood1, Sarah A Teele, Cindy S Barrett
1Department of Cardiology, Children's Hospital Boston, Mass 02115, USA. kelly.rood@cardio.chboston.org
Insights
Extracorporeal membrane oxygenation (ECMO) after Fontan operation has high mortality. Neurologic injury, surgical bleeding, and renal failure increase ECMO-related death, while longer ECMO duration may improve survival.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- The Fontan operation is a palliative procedure for complex single-ventricle congenital heart disease.
- Post-Fontan cardiac failure can necessitate mechanical circulatory support, such as extracorporeal membrane oxygenation (ECMO).
- High mortality rates and unclear causes of death in these patients highlight the need for further investigation.
Purpose of the Study:
- To evaluate in-hospital mortality rates in pediatric patients requiring ECMO after the Fontan operation.
- To identify factors associated with increased mortality in this high-risk population.
Main Methods:
- Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) registry data (1987-2009).
- Inclusion of pediatric patients who underwent ECMO post-Fontan operation.
- Comparison of demographics and ECMO data between survivors and nonsurvivors, utilizing multivariable logistic regression to identify mortality predictors.
Main Results:
- Of 230 patients, 35% survived to hospital discharge.
- Nonsurvivors showed higher rates of pre-ECMO cardiopulmonary resuscitation and higher fraction of inspired oxygen.
- Neurologic injury (OR 5.18), surgical bleeding (OR 2.36), and renal failure (OR 2.81) significantly increased mortality.
- ECMO duration between 65-119 hours was associated with decreased mortality (OR 0.33).
Conclusions:
- Cardiac failure requiring ECMO post-Fontan operation is associated with substantial in-hospital mortality.
- Complications during ECMO support, including neurologic injury, surgical bleeding, and renal failure, are significant contributors to mortality.
- Timely surgical intervention for bleeding may improve survival outcomes in these critically ill children.
Objective:
Extracorporeal membrane oxygenation has been used to support children with cardiac failure after the Fontan operation. Mortality is high, and causes of mortality remain unclear. We evaluated the in-hospital mortality and factors associated with mortality in these patients.
Methods:
Extracorporeal Life Support Organization registry data on patients requiring extracorporeal membrane oxygenation after the Fontan operation from 1987 to 2009 were retrospectively analyzed. Demographics and extracorporeal membrane oxygenation data were compared for survivors and nonsurvivors. A multivariable logistic regression model was used to identify factors associated with mortality.
Results:
Of 230 patients, 81 (35%) survived to hospital discharge. Cardiopulmonary resuscitation was more frequent (34% vs 17%, P = .04), and median fraction of inspired oxygen concentration was higher (1 [confidence interval, 0.9-1.0] vs 0.9 [confidence interval, 0.8-1.0], P = .03) before extracorporeal membrane oxygenation in nonsurvivors compared with survivors. Extracorporeal membrane oxygenation duration and incidence of complications, including surgical bleeding, neurologic injury, renal failure, inotrope use on extracorporeal membrane oxygenation, and bloodstream infection, were higher in nonsurvivors compared with survivors (P < .05 for all). In a multivariable model, neurologic injury (odds ratio, 5.18; 95% confidence interval, 1.97-13.61), surgical bleeding (odds ratio, 2.36; 95% confidence interval, 1.22-4.56), and renal failure (odds ratio, 2.81; 95% confidence interval, 1.41-5.59) increased mortality. Extracorporeal membrane oxygenation duration of more than 65 hours to 119 hours (odds ratio, 0.33; 95% confidence interval, 0.14-0.76) was associated with decreased mortality.
Conclusions:
Cardiac failure requiring extracorporeal membrane oxygenation after the Fontan operation is associated with high mortality. Complications during extracorporeal membrane oxygenation support increase mortality odds. Prompt correction of surgical bleeding when possible may improve survival.
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