Extracorporeal Membrane Oxygenation After Norwood Surgery in Patients With Hypoplastic Left Heart Syndrome: A Retrospective Single-Center Cohort Study From Brazil

Abstract

BackgroundExtracorporeal membrane oxygenation (ECMO) is increasingly being used to support patients after the repair of congenital heart disease.ObjectiveWe report our experience with patients with a single functional ventricle who were supported by ECMO after the Norwood procedure, reviewing the outcomes and identifying risk factors for mortality in these patients.MethodsIn this single-center retrospective cohort study, we enrolled 33 patients with hypoplastic left heart syndrome (HLHS) who received ECMO support after the Norwood procedure between January 2015 and December 2019. The independent variables evaluated in this study were demographic, anatomical, and those directly related to ECMO support (ECMO indication, local of initiation, time under support, and urinary output while on ECMO). The dependent variable was survival. A p < 0.05 was considered statistically significant.ResultsThe ECMO support was applied in 33 patients in a group of 120 patients submitted to Norwood procedure (28%). Aortic atresia was present in 72.7% of patients and mitral atresia in 51.5%. For 15% of patients, ECMO was initiated in the operating room; for all other patients, ECMO was initiated in the intensive care unit. The indications for ECMO in the cardiac intensive care unit were cardiac arrest in 22 (79%) of patients, low cardiac output state in 10 (18%), and arrhythmia in 1 patient (3%). The median time under support was 5 (2–25) days. The median follow-up time was 59 (4–150) days. Global survival to Norwood procedure was 90.9% during the 30-day follow-up, being 33.3% for those submitted to ECMO. Longer ECMO support (p = 0.004) was associated with a higher risk of death in the group submitted to ECMO.ConclusionsThe mortality of patients with HLHS who received ECMO support after stage 1 palliation was high. Patients with low urine output were related to worse survival rates, and longer periods under ECMO support (more than 9 days of ECMO) were associated with 100% mortality. Earlier ECMO initiation before multiorgan damage may improve results.

Short‐Term Mortality Among Pediatric Patients With Heart Diseases Undergoing Veno‐Arterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta‐Analysis

“…We further excluded 42 studies after full‐text evaluation, because they did not meet inclusion criteria. Eventually, 28 studies 11 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 were amenable to meta‐analysis (Figure 1 ).…”

“…In our meta‐analysis, applying a random‐effects model, the pooled short‐term mortality (28 studies,1736 patients) was 45.6% (95% CI, 38.7%–52.4%) (Figure 2 ). 11 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 There was no evidence for publication bias because of the funnel plot appearing visually symmetrical (Figure 3 ), and the Egger test suggesting insignificant difference for our primary outcome of interest ( P egger =0.23). The sensitivity analysis performed by excluding the studies with a Joanna Briggs Institute score <8, showed that the pooled short‐term mortality was 46.2% (95% CI, 39.0%–53.4%).…”

“…After excluding 5 studies that included a few patients with arrhythmias, cardiomyopathy, and others, we found a short‐term mortality of 48.9% (95% CI, 42.3%–55.6%) (Figure S1 ). 19 , 20 , 21 , 22 , 23 , 24 , 26 , 27 , 28 , 29 , 31 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 Removing studies reporting 30‐day mortality, the pooled mortality was 45.4% (95% CI, 37.9%–52.9%) (Figure S2 ). 11 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 29 , 30 , 31 , 32 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 45 The similar short‐term mortality ind...…”

“…Additionally, a leave‐1‐out sensitivity analysis revealed that no individual study significantly changed the pooled short‐term mortality, indicating the results remained stable (Figure S3 ). 11 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 The main results of the meta‐analysis are presented in Table 1 . Furthermore, the overall proportions exhibited similarity to the average rates obtained through simple pooling (Table S5 ), suggesting the robustness of the findings despite significant heterogeneity.…”

“…Our findings indicated that VA‐ECMO mortality was higher during the early 21st century in comparison with the other 2 periods, although no significant differences were observed between subgroups ( P =0.248) (Figure 4 ). 11 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 The pooled short‐term mortality in North America was 47.0% (95% CI, 37.8%–56.2%) and 44.6% (95% CI, 34.7%–54.5%) in Asia, with no significant difference between subgroups ( P =0.731) (Figure 5 ). 11 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ...…”