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Predictors and Outcome of Extracorporeal Life Support After Pediatric Heart Transplantation
Jacob Simmonds1, Troy Dominguez1, Joanna Longman1
1Cardiac Unit, Great Ormond Street Hospital, London, United Kingdom.
Insights
Extracorporeal life support (ECLS) is vital after pediatric heart transplants, especially for restrictive cardiomyopathy. While initial survival is challenging, ECLS offers excellent medium-term graft survival for critically ill children.
Area of Science:
- Pediatric Cardiology
- Cardiothoracic Surgery
- Critical Care Medicine
Background:
- Extracorporeal life support (ECLS) is established after conventional cardiac surgery but less documented in pediatric heart transplantation.
- This study investigates ECLS use, predisposing factors, morbidity, and mortality in pediatric heart transplant recipients.
Purpose of the Study:
- To analyze the incidence of ECLS use after pediatric heart transplantation.
- To identify factors associated with ECLS requirement.
- To evaluate outcomes, including graft survival, in patients requiring ECLS post-transplant.
Main Methods:
- Retrospective review of 202 pediatric heart transplant recipients (ages 0.06-17.91) at Great Ormond Street Hospital (1999-2009).
- Patients categorized by diagnosis: restrictive cardiomyopathy (n=17), nonrestrictive cardiomyopathy (n=134), and anatomic heart disease (n=51).
- Analysis of ECLS requirement, predisposing factors, and survival rates.
Main Results:
- 13.9% (28/202) of patients required ECLS post-transplantation.
- Restrictive cardiomyopathy (35.3%) was significantly associated with higher ECLS need compared to other diagnoses.
- Longer ischemic times and pre-transplant extracorporeal membrane oxygenation were linked to post-transplant ECLS requirement.
Conclusions:
- ECLS use after pediatric heart transplantation was higher than anticipated.
- Despite significant initial morbidity and mortality, patients requiring ECLS demonstrated excellent medium-term survival.
- Judicious use of ECLS is recommended for critically ill pediatric heart transplant recipients, offering a chance for survival.
Background:
Extracorporeal life support (ECLS) has proven success after conventional cardiac surgery. Its use after pediatric heart transplantation is less well documented. We reviewed ECLS after pediatric heart transplantation, to understand better predisposing factors, morbidity, and mortality.
Methods:
The notes of all patients at Great Ormond Street Hospital undergoing orthotopic heart transplantation from 1999 to 2009 were reviewed (202 transplants; patients aged 0.06 to 17.91 years). Patients were grouped by diagnosis: restrictive cardiomyopathy (n = 17), nonrestrictive cardiomyopathy (n = 134), and anatomic heart disease (n = 51).
Results:
Twenty-eight patients (13.9%) required ECLS after transplantation. Those requiring ECLS had longer ischemic times (4.2 versus 3.7 hours, p = 0.02). More restrictive cardiomyopathy patients (35.3%) required ECLS-higher than dilated cardiomyopathy (10.4%) or anatomic heart disease (15.7%; χ(2) 7.99; p = 0.018). Factors associated with posttransplant ECLS were restrictive cardiomyopathy, longer ischemic time, and extracorporeal membrane oxygenation before transplant. Graft survival was higher in the non-ECLS group, with 1-year survival of 98.2% versus 57.7%; however, medium-term survival was comparable, with 5-year survival for those surviving to hospital discharge being 84.7% versus 100%.
Conclusions:
The requirement for ECLS was higher than expected for conventional cardiac surgery. Although just over one half of patients requiring ECLS survived to discharge, they had excellent medium-term survival, with all still alive. Although ECLS is an expensive, invasive therapy, with significant morbidity and mortality, without it, those patients would have perished. Its judicious use, therefore, can be recommended.
