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Extracorporeal membrane oxygenation in children after Fontan operation
Pilar Anton-Martin1, Rodrigo Cardoso Cavalcante1, Lindsay Master2
1Division of Cardiac Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa.
Insights
Survival after extracorporeal membrane oxygenation (ECMO) for pediatric Fontan patients has improved. Avoiding pre-ECMO arrest and enabling earlier cannulation may enhance outcomes for these complex cases.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- The Fontan operation is a palliative procedure for complex single-ventricle congenital heart disease.
- Extracorporeal membrane oxygenation (ECMO) is a life-support measure used in critically ill patients.
- Outcomes for pediatric patients requiring ECMO post-Fontan palliation are not well-defined.
Purpose of the Study:
- To investigate the outcomes of pediatric patients who require ECMO following the Fontan operation.
- To identify factors associated with survival in this high-risk population.
Main Methods:
- Retrospective cohort analysis of the Extracorporeal Life Support Organization (ELSO) registry.
- Inclusion criteria: patients <18 years old undergoing ECMO after Fontan palliation between 2010-2023 during their surgical hospitalization.
- Data collected included patient demographics, ECMO characteristics, and clinical outcomes.
Main Results:
- Survival to hospital discharge was 48.4% among 281 children.
- Veno-arterial ECMO was the predominant support strategy (92%).
- Independent predictors of mortality included pre-ECMO arrest, bicarbonate administration, higher ECMO flow, longer ECMO duration, delayed cannulation, and neurologic, renal, or pulmonary complications.
Conclusions:
- Hospital survival after ECMO post-Fontan palliation shows improvement compared to historical data.
- Avoiding pre-ECMO arrest and achieving earlier cannulation are potentially modifiable factors to improve outcomes.
- Further prospective studies are needed to optimize timing and support strategies for this patient group.
Objective:
To investigate the outcomes of pediatric patients requiring extracorporeal membrane oxygenation (ECMO) after the Fontan operation.
Methods:
We conducted a retrospective cohort analysis of the Extracorporeal Life Support Organization registry, including patients <18 years who underwent ECMO after Fontan palliation from 2010 to 2023. Patients undergoing a first ECMO run during their hospitalization for Fontan surgery were included.
Results:
Among 281 children undergoing ECMO after Fontan palliation, survival at hospital discharge was 48.4%. Median age and weight were 3.9 years (interquartile range [IQR], 2.7-5.5) and 15 kg (IQR, 12-19), respectively. Venoarterial ECMO was used in 92% of patients, multiple drainage cannulas in 21%, central cannulation in 49%, and Fontan pathway decompression in 51%. Survival did not differ according to the use of multiple drainage cannulas or decompression strategy. Independent predictors of hospital mortality included pre-ECMO arrest (odds ratio [OR], 1.88; P = .042), pre-ECMO bicarbonate administration (OR, 2.01; P = .019), higher ECMO flow at 4 hours (OR, 1.01; P = .014), longer ECMO duration (OR, 1.09; P = .002), longer admission-to-cannulation time (OR, 1.04; P = .002), and neurologic (OR, 5.99; P < .001), renal (OR, 2.92; P = .005), or pulmonary complications (OR, 13.07; P = .022). Eight patients were transitioned to ventricular assist device support after ECMO, and 6 underwent heart transplantation; survival in both groups was 50%.
Conclusions:
Hospital survival after ECMO following Fontan palliation has improved compared with prior reports. The avoidance of pre-ECMO arrest and earlier cannulation are potentially modifiable factors that may improve outcomes for these patients. Prospective studies are warranted to better define the timing, outcomes, and optimal support strategies in this population.
