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Outcome-associated factors in pediatric patients treated with extracorporeal membrane oxygenator after cardiac
T J Kulik1, F W Moler, J M Palmisano
1Department of Pediatrics, University of Michigan, Ann Arbor, USA.
Insights
Extracorporeal membrane oxygenation (ECMO) after congenital heart surgery has low survival rates. Factors like single ventricle diagnosis and delayed ECMO initiation significantly impact patient outcomes.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- Extracorporeal membrane oxygenation (ECMO) use in postoperative cardiac patients has lower success rates compared to neonates.
- The reasons for reduced ECMO efficacy in pediatric cardiac surgery are not well understood.
Purpose of the Study:
- To retrospectively analyze factors influencing hospital survival in pediatric patients undergoing ECMO after congenital heart surgery.
- To identify predictors of ECMO success and failure in this specific patient population.
Main Methods:
- Retrospective analysis of 64 pediatric patients who received ECMO after congenital heart surgery between 1981 and 1995.
- Patients were categorized based on surgical repair: two-ventricular (A), aortopulmonary shunt (B), or cavopulmonary connection (C).
- Indications for ECMO included ventricular dysfunction, pulmonary failure, pulmonary hypertension, or combinations thereof.
Main Results:
- Overall hospital survival was 33%. Group A (two-ventricular repair) had 42% survival, while groups B (shunt) and C (cavopulmonary connection) had 25% and 17% survival, respectively.
- Survival was not related to the ECMO indication but was lower with initiation in the operating room or >50 hours post-surgery.
- Prolonged ECMO use (>208 hours) was associated with no survival, except for one case of pneumonia. Neurological and multiple complications were frequent reasons for ECMO discontinuation in non-survivors.
Conclusions:
- Single ventricle diagnosis, ECMO initiation in the operating room or >50 hours post-surgery, and ECMO duration >208 hours are associated with nonsurvival.
- Noncardiac complications were more common causes for ECMO discontinuation than failure of cardiac function recovery.
Background:
The use of the extracorporeal membrane oxygenator (ECMO) for postoperative cardiac patients has not resulted in the same high success rate as when ECMO is used for neonates with pulmonary hypertension or pulmonary failure. The reason for this is poorly understood.
Methods And Results:
We analyzed retrospectively all pediatric patients placed on ECMO after surgery for a congenital heart lesion between 1981 and 1995 (n = 64). Patients had a two-ventricular repair (A) or pulmonary blood flow supplied by an aortopulmonary shunt (B) or by a cavopulmonary connection (C). Indication for ECMO was unsatisfactory hemodynamics due to (1) ventricular dysfunction, (2) pulmonary failure, (3) pulmonary hypertension, or (4) a combination or (5) for unclear reasons. Hospital survival was related to these and other factors. Overall hospital survival was 33%; 42% of group A patients survived to discharge, whereas only 25% and 17% survived in groups B and C, respectively. Survival was unrelated to the indication for ECMO but appeared to be lower when ECMO was initiated in the operating room or > 50 hours after surgery. Except for one patient with pneumonia, no patient survived who was on ECMO for > 208 hours. ECMO discontinuation in nonsurvivors was due to neurological (30%) or multiple complications (39%), the lack of return of cardiac function (12%), or other reasons (15%).
Conclusions:
This review suggests that the diagnosis of single ventricle, initiation of ECMO in the operating room or > 50 hours after surgery, and ECMO for > 208 hours are associated with patient nonsurvival. Noncardiac complications more frequently led to discontinuation of ECMO than did failure of the return of cardiac function.