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Extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock in children
A J Rogers1, A Trento, R D Siewers
1Department of Surgery, University of Pittsburgh School of Medicine, Pennsylvania.
Insights
Extracorporeal membrane oxygenation (ECMO) effectively supports children with postcardiotomy ventricular dysfunction, improving survival rates. This pediatric cardiac support method offers a viable solution when conventional systems fail, demonstrating significant long-term success.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- Conventional mechanical circulatory support systems face size and technical limitations for pediatric postcardiotomy ventricular dysfunction.
- Extracorporeal membrane oxygenation (ECMO), typically for neonatal respiratory failure, can provide essential cardiac support in children.
- Postoperative myocardial failure in children presents a significant clinical challenge.
Purpose of the Study:
- To evaluate the efficacy and outcomes of using ECMO for pediatric patients experiencing ventricular dysfunction after cardiac surgery.
- To assess the feasibility of ECMO as a mechanical circulatory support in a pediatric population.
- To determine the survival rates and morbidity associated with ECMO use in this specific patient group.
Main Methods:
- A retrospective analysis of 10 pediatric patients (2 days to 5 years) treated with venoarterial ECMO from 1981 to 1987 following cardiotomy.
- Detailed documentation of operative procedures, ECMO duration (15-144 hours), cannulation techniques, and patient outcomes.
- Inclusion of various complex congenital heart defect repairs, such as tetralogy of Fallot, VSD closure, and Fontan procedure.
Main Results:
- Eight out of ten patients were successfully weaned from ECMO, with seven achieving long-term survival.
- Three patients experienced mortality; causes included sepsis with multi-organ failure, post-repair complications, and massive pulmonary hemorrhage.
- Major hemorrhage occurred in three patients, necessitating premature decannulation in two who subsequently survived; one died from respiratory failure due to bleeding.
Conclusions:
- ECMO is an effective treatment for transient postoperative ventricular dysfunction in pediatric patients, significantly improving survival.
- The use of ECMO in this pediatric cohort demonstrated limited overall morbidity despite the severity of cases.
- ECMO provides a crucial therapeutic option for pediatric cardiac support when traditional methods are inadequate.
Abstract:
Size limitations and technical barriers prohibit the use of many conventional mechanical circulatory support systems for postcardiotomy ventricular dysfunction in pediatric populations. Extracorporeal membrane oxygenation (ECMO), frequently used to treat neonatal respiratory failure, can provide cardiac support and is effective treatment of postoperative myocardial failure in children. From 1981 to 1987, 10 patients aged 2 days to 5 years were maintained on ECMO for 15 to 144 hours (mean duration, 92 +/- 16 hours) after cardiotomy. Operative procedures included repair of tetralogy of Fallot (2 patients), closure of a ventricular septal defect (2), the Senning procedure for transposition of the great arteries (1 patient), repair of interrupted aortic arch with closure of a ventricular septal defect (1), repair of a partial atrioventricular septal defect (2), closure of a ventricular septal defect with excision of an anomalous muscle bundle (1), and the Fontan procedure (1). Venoarterial ECMO was established in all 10 children. Six patients underwent transthoracic right atrium-ascending aorta cannulation, 3 had right internal jugular vein-right common carotid artery cannulation through a cervical incision, and 1 had right internal jugular vein-left axillary artery cannulation. Eight of the 10 patients were successfully weaned from ECMO, and 7 are long-term survivors. There were 3 deaths; 1 was caused by cardiac and acute renal failure complicated by sepsis two days after decannulation, another occurred 19 days after atrioventricular septal defect repair, and 1 was caused by massive pulmonary hemorrhage. Major hemorrhage developed in 3 patients while on ECMO; 2 required premature decannulation for mediastinal bleeding from operative sites and ultimately survived, and 1 died of respiratory failure as a result of endobronchial bleeding. We conclude that the use of ECMO in pediatric populations for transient postoperative ventricular dysfunction improves survival with limited overall morbidity.