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Pediatric cardiac surgical ECMO: multivariate analysis of risk factors for hospital death
H L Walters1, M Hakimi, M D Rice
1Department of Cardiovascular Surgery, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit 48201, USA.
Insights
Extracorporeal membrane oxygenation (ECMO) effectively supports pediatric cardiac patients. Postoperative ECMO (Group 2B) shows higher survival than immediate post-repair ECMO (Group 2A), with right atrial pressure predicting outcomes.
Area of Science:
- Pediatric Cardiology
- Cardiothoracic Surgery
- Mechanical Circulatory Support
Background:
- Extracorporeal membrane oxygenation (ECMO) is a critical intervention for pediatric patients with refractory cardiac failure post-cardiac surgery.
- Medically refractory cardiac failure presents a significant challenge in the pediatric postcardiotomy population.
Purpose of the Study:
- To evaluate the effectiveness of ECMO in pediatric cardiac surgical patients.
- To compare outcomes based on the timing of ECMO cannulation relative to cardiac repair.
- To identify risk factors for hospital mortality in this patient group.
Main Methods:
- Retrospective review of 73 pediatric congenital heart disease patients undergoing ECMO (1984-1994).
- Patients categorized into preoperative ECMO (Group 1) and postoperative ECMO (Group 2).
- Subgroup analysis of Group 2 into immediate post-cardiac repair ECMO (2A) and delayed postoperative ECMO (2B).
Main Results:
- Overall hospital survival was 58% (42/73).
- Group 2B patients (delayed postoperative ECMO) had significantly higher survival (69.4%) compared to Group 2A (immediate post-repair ECMO) (23.5%, p=0.001).
- Elevated right atrial pressure post-ECMO decannulation and Group 2A status were independent risk factors for mortality.
Conclusions:
- ECMO is most effective for pediatric cardiac surgical patients with refractory hemodynamic deterioration after successful weaning from cardiopulmonary bypass.
- Delayed postoperative ECMO (Group 2B) is associated with better survival outcomes.
- Right atrial pressure post-ECMO decannulation is a significant predictor of hospital mortality.
Background:
Extracorporeal membrane oxygenation (ECMO) has emerged as an effective technique for the mechanical support of many pediatric postcardiotomy patients with medically refractory cardiac failure.
Methods:
We retrospectively reviewed the records of 73 pediatric patients with congenital heart disease who were placed on ECMO support between August 1984 and February 1994. The patients were divided into groups defined by the timing of ECMO cannulation relative to the time of operation. Group 1 patients (n = 7, 9.6%) were placed on ECMO preoperatively. Group 2 patients (n = 66, 90.4%) were a heterogeneous population placed on ECMO at any interval after cardiac repair. Subgroup 2A consisted of patients (n = 17, 25.8%) who could not be weaned from cardiopulmonary bypass and were converted directly to ECMO support immediately after repair. Subgroup 2B patients (n = 49, 74.2%) were cannulated postoperatively after an initial period of clinical stability.
Results:
Hospital survival for all study patients (42/73) and for group 2 patients (38/66) was 58%. Only 4 group 2A patients (23.5%) survived their hospitalization compared with 34 group 2B patients (69.4%) (p = 0.001). Multivariate analysis identified elevated right atrial pressure after ECMO decannulation (p = 0.049) and, possibly, membership in group 2A (p = 0.061) as independent risk factors for hospital death.
Conclusions:
Extracorporeal membrane oxygenation is most effective in salvaging pediatric cardiac surgical patients who demonstrate medically refractory hemodynamic deterioration at some interval after being successfully weaned from cardiopulmonary bypass. The right atrial pressure after extracorporeal membrane oxygenation decannulation is an independent predictor of hospital death.