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Increasing Pulmonary Artery Pulsatile Flow Improves Hypoxic Pulmonary Hypertension in Piglets
Published on: May 11, 2015
Extracorporeal membrane oxygenation (ECMO) support for children with pulmonary hypertension: A single-institutional
Christopher Nemeh1, Nicholas Schmoke1, William Patten2
1Department of Surgery, Division of Pediatric Surgery Columbia University Vagelos College of Physicians and Surgeons/NewYork-Presbyterian Morgan Stanley Children's Hospital New York New York USA.
Insights
Pediatric pulmonary arterial hypertension (PAH) patients needing extracorporeal membrane oxygenation (ECMO) have high mortality. Venovenous ECMO showed better survival than venoarterial ECMO, suggesting tailored approaches improve outcomes.
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Pulmonary Hypertension Research
Background:
- Pediatric pulmonary arterial hypertension (PAH) presents with variable severity.
- Pulmonary hypertension (PH) crises can cause acute decompensation, necessitating extracorporeal membrane oxygenation (ECMO) support, including extracorporeal cardiopulmonary resuscitation (eCPR).
Purpose of the Study:
- To evaluate the outcomes of pediatric PH patients requiring ECMO support.
- To identify factors associated with survival in this high-risk population.
Main Methods:
- A retrospective review of 20 pediatric PAH patients (WSPH groups 1 and 3) requiring ECMO from 2010-2022.
- Analysis of primary outcome (survival to hospital discharge) and secondary outcomes (survival to decannulation and 1-year survival).
- Univariate logistic regression was used to assess the impact of ECMO configuration and other factors on survival.
Main Results:
- Overall survival to discharge was 40% (8/20 patients).
- Survival to decannulation was 80% (16/20 patients).
- Venovenous (VV) ECMO was associated with significantly better survival to discharge compared to venoarterial (VA) ECMO (OR: 0.12, p=0.046).
Conclusions:
- Pediatric PAH patients requiring ECMO face high mortality, highlighting the complexity of their management.
- VV ECMO may offer survival benefits over VA ECMO in select cases, warranting consideration based on patient-specific factors.
- A multidisciplinary, case-by-case approach is crucial for managing these critically ill children.
Abstract:
Pediatric pulmonary arterial hypertension (PAH) can present with a wide spectrum of disease severity. Pulmonary hypertension (PH) crises can lead to acute decompensation requiring extracorporeal membrane oxygenation (ECMO) support, including extracorporeal cardiopulmonary resuscitation (eCPR). We evaluated outcomes for pediatric PH patients requiring ECMO. A single-institution retrospective review of pediatric PAH patients with World Symposium on PH (WSPH) groups 1 and 3 requiring ECMO cannulation from 2010 through 2022 (n = 20) was performed. Primary outcome was survival to hospital discharge. Secondary outcomes were survival to decannulation and 1-year survival. Of 20 ECMO patients, 16 (80%) survived to decannulation and 8 (40%) survived to discharge and 1 year follow up. Of three patients who had two ECMO runs; none survived. There were five patients who had eCPR for the first run; one survived to discharge. The univariate logistic regression model showed that venovenous ECMO was associated with better survival to hospital discharge than venoarterial ECMO, (OR: 0.12, 95% CI: 0.01-0.86, p = 0.046). PH medications (administered before, during, or after ECMO) were not associated with survival to discharge. For children with decompensated PAH requiring ECMO, mortality rate is high, and management is challenging. While VA ECMO is the main configuration for decompensated PH, VV ECMO could be considered if there is adequate ventricular function, presence of a systemic to pulmonary shunt, or an intercurrent treatable illness to improve survival to discharge. A multidisciplinary approach with requisite expertise should be utilized on a case-by-case basis until more reliable data is available to predict outcomes.
