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Extracorporeal Membrane Oxygenation Cannulation Timing in the Pediatric Myocarditis Population: An Exploratory
Maria E Gutierrez1, Marc Anders2, Danielle Guffey3
1Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
Insights
Early extracorporeal membrane oxygenation (ECMO) cannulation after intubation improves survival in pediatric myocarditis patients not experiencing cardiac arrest. Prompt ECMO initiation is key for better outcomes in this critical condition.
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Cardiovascular Research
Background:
- Acute myocarditis can cause rapid clinical deterioration in children.
- Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for severe cases.
- Optimal timing and best practices for ECMO initiation in pediatric myocarditis are not well-established.
Purpose of the Study:
- To explore pre-cannulation factors influencing survival in pediatric myocarditis patients requiring ECMO.
- To investigate the relationship between timing of ECMO initiation and patient outcomes.
- To identify predictors of survival in this high-acuity population.
Main Methods:
- Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) registry (2007-2018).
- Inclusion of pediatric patients (≤18 years) with myocarditis receiving venoarterial ECMO.
- Primary outcome: survival to hospital discharge, stratified by pre-ECMO cardiac arrest (CA) and intubation-to-cannulation (ITC) time.
Main Results:
- Overall survival was 72% across 506 ECMO runs.
- Survivors had higher pre-ECMO pH and shorter ITC times.
- Longer ITC time was associated with lower survival in patients without pre-ECMO CA (aOR 0.09; P=0.002).
Conclusions:
- Early ECMO cannulation after intubation may improve survival in pediatric myocarditis patients without prior cardiac arrest.
- This multicenter analysis highlights the importance of timely ECMO initiation.
- Further research into best practices for ECMO management in pediatric myocarditis is warranted.
Abstract:
Children presenting with acute myocarditis may experience rapid clinical deterioration requiring extracorporeal membrane oxygenation (ECMO); however, our understanding of best practices and timing of ECMO initiation are lacking. We explored the relationships between pre-cannulation factors and survival in this high-acuity patient population.
Design:
Retrospective review of a large international registry. Primary outcome was survival to hospital discharge, stratified by incident cardiac arrest (CA) prior to ECMO and time to cannulation after intubation.
Setting And Subjects:
The Extracorporeal Life Support Organization registry was queried for patients less than or equal to 18 years old receiving ECMO support for myocarditis between 2007 and 2018. Exclusion criteria included being nonindex runs, non-venoarterial ECMO or missing data points for main variables studied.
Interventions:
None.
Measurements And Main Results:
Population characteristics and survival were compared using t test, Wilcoxon rank-sum test, or Fisher exact test. Multivariable logistic regression was used for significant factors in the unadjusted logistic regression. Among 506 index ECMO runs in pediatric patients with myocarditis, survival for the cohort was 72%, with no difference between early and late eras (2007-2012 vs 2013-2018; p = 0.69). Survivors demonstrated higher pre-ECMO pH levels as well as shorter intubation-to-cannulation (ITC) times (3 hr [interquartile range (IQR)], 1-14 hr vs 6 hr [IQR, 2-20 hr]; p = 0.021). CA occurred within 24 hours prior to ECMO cannulation, including extracorporeal cardiopulmonary resuscitation, in 54% of ECMO runs (n = 273). Accounting for the interaction between pre-ECMO CA occurrence and ITC time, longer ITC time remained associated with lower survival for patients who did not experience a CA prior to ECMO, with adjusted odds ratio of 0.09 (IQR, 0.02-0.40; p = 0.002) for ITC time greater than or equal to 18 hours.
Conclusions:
The results of this multicenter analysis of ECMO utilization and outcomes for pediatric myocarditis suggest that patients approaching ECMO cannulation who have not experienced CA may have better survival outcomes if cannulated onto ECMO early after intubation.
