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Modeling severe functional impairment or death following ECPR in pediatric cardiac patients: Planning for an
Francesca Sperotto1, Kwannapas Saengsin2, Amy Danehy3
1Departments of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA; Pediatric Intensive Care Unit, Department of Women's and Children's Health, University of Padova, Via Giustiniani 2, Padova 35128, Italy.
Insights
Extracorporeal CPR (ECPR) in children has high mortality and functional impairment. Accurate prediction models using daily data can identify high-risk patients and potential trial endpoints.
Area of Science:
- Pediatric critical care medicine
- Cardiovascular research
- Neurology
Background:
- Extracorporeal CPR (ECPR) is a life-saving intervention for pediatric in-hospital cardiac arrest.
- Outcomes and predictors of severe functional impairment or death following ECPR in children are not well-characterized.
- Congenital heart disease is a common comorbidity in pediatric ECPR patients.
Purpose of the Study:
- To characterize ECPR outcomes in a pediatric center.
- To develop a predictive model for severe functional impairment or death at discharge after ECPR.
- To identify independent predictors of poor outcomes in this population.
Main Methods:
- Retrospective review of 214 pediatric ECPR events (2011-2019).
- Primary outcome: severe functional impairment or death at discharge (Functional Status Score [FSS] ≥ 16).
- Multivariable logistic regression used to model FSS ≥ 16, incorporating organ dysfunction (PELOD-2) and neuroimaging (mASPECTS) scores.
Main Results:
- 182 patients with in-hospital cardiac arrest and congenital heart disease were analyzed.
- In-hospital mortality was 52%, with 87% of deaths due to withdrawal of life-sustaining therapies, often influenced by severe neurologic injury.
- Predictive models (AUC = 0.931) identified FSS at admission, single ventricle physiology, ECMO duration, PELOD-2, and mASPECTS as independent predictors of severe impairment or death.
Conclusions:
- Pediatric ECPR is associated with high mortality and functional impairment.
- Accurate predictive models for severe functional impairment or death at discharge can be developed using daily post-ECPR data.
- These models serve as valuable prognostic tools and may guide future interventional trials in pediatric ECPR.
Aim:
We aimed to characterize extracorporeal CPR (ECPR) outcomes in our center and to model prediction of severe functional impairment or death at discharge.
Methods:
All ECPR events between 2011 and 2019 were reviewed. The primary outcome measure was severe functional impairment or death at discharge (Functional Status Score [FSS] ≥ 16). Organ dysfunction was graded using the Pediatric Logistic Organ Dysfunction Score-2, neuroimaging using the modified Alberta Stroke Program Early Computed Tomography Score. Multivariable logistic regression was used to model FSS ≥ 16 at discharge.
Results:
Of the 214 patients who underwent ECPR, 182 (median age 148 days, IQR 14-827) had an in-hospital cardiac arrest and congenital heart disease and were included in the analysis. Of the 110 patients who underwent neuroimaging, 52 (47%) had hypoxic-ischemic injury and 45 (41%) had hemorrhage. In-hospital mortality was 52% at discharge. Of these, 87% died from the withdrawal of life-sustaining therapies; severe neurologic injury was a contributing factor in the decision to withdraw life-sustaining therapies in 50%. The median FSS among survivors was 8 (IQR 6-8), and only one survivor had severe functional impairment. At 6 months, mortality was 57%, and the median FSS among survivors was 6 (IQR 6-8, n = 79). Predictive models identified FSS at admission, single ventricle physiology, extracorporeal membrane oxygenation (ECMO) duration, mean PELOD-2, and worst mASPECTS (or DWI-ASPECTS) as independent predictors of FSS ≥ 16 (AUC = 0.931) and at 6 months (AUC = 0.924).
Conclusion:
Mortality and functional impairment following ECPR in children remain high. It is possible to model severe functional impairment or death at discharge with high accuracy using daily post-ECPR data up to 28 days. This represents a prognostically valuable tool and may identify endpoints for future interventional trials.
