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Recurrent or prolonged mechanical circulatory support: bridge to recovery or road to nowhere?

Yves d'Udekem1, Nobuaki Shime, Song Lou

  • 1Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia. yves.dudekem@rch.org.au

Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
|June 6, 2013
PubMed

Insights

For pediatric respiratory failure, extracorporeal membrane oxygenation (ECMO) offers prolonged support. However, for cardiac failure, ECMO beyond two weeks offers limited benefit, necessitating transition to ventricular assist devices or considering transplantation.

Area of Science:

  • Pediatric Critical Care Medicine
  • Cardiovascular Surgery
  • Mechanical Circulatory Support

Background:

  • Prolonged mechanical circulatory support (MCS) in children yields remarkable outcomes, yet futility thresholds remain unclear.
  • Extracorporeal membrane oxygenation (ECMO) survival for pediatric respiratory failure declines with support duration.
  • Cardiac failure management with MCS differs significantly from respiratory failure, with shorter effective support windows.

Purpose of the Study:

  • To delineate the optimal duration of extracorporeal membrane oxygenation (ECMO) in pediatric patients with cardiac versus respiratory failure.
  • To establish evidence-based guidelines for transitioning patients from ECMO to alternative mechanical circulatory support.
  • To evaluate the efficacy and outcomes of repeat ECMO interventions in pediatric patients.

Main Methods:

  • Review of clinical outcomes and survival data for pediatric patients undergoing prolonged mechanical circulatory support.
  • Analysis of extracorporeal membrane oxygenation (ECMO) duration in relation to patient diagnosis (respiratory vs. cardiac failure).
  • Evaluation of transition strategies to ventricular assist devices (VADs) and outcomes of repeat ECMO interventions.

Main Results:

  • Extracorporeal membrane oxygenation (ECMO) can support pediatric respiratory failure for extended periods (weeks to months) if managed without complications.
  • For pediatric cardiac failure, ECMO support beyond two weeks shows limited efficacy, with survival beyond 12 days in post-cardiac surgery patients being anecdotal.
  • Repeat ECMO offers minimal long-term benefit unless organ transplantation is pursued; transition to VADs is recommended after two weeks without recovery.

Conclusions:

  • Extracorporeal membrane oxygenation (ECMO) is viable for prolonged pediatric respiratory support but has a limited therapeutic window for cardiac failure.
  • Transitioning pediatric cardiac failure patients to ventricular assist devices (VADs) after two weeks of ECMO is critical for improved outcomes.
  • Repeat ECMO interventions in pediatric patients are generally not recommended due to poor long-term survival, except in the context of organ transplantation.

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