Impact of Timing of ECMO Initiation on Outcomes After Pediatric Heart Surgery: A Multi-Institutional Analysis

Gupta, Punkaj; Robertson, Michael J.; Rettiganti, Mallikarjuna; Seib, Paul M.; Wernovsky, Gil; Markovitz, Barry P.; Simsic, Janet M.; Tobias, Joseph D.

doi:10.1007/s00246-016-1379-6

Cited by 44 publications

(62 citation statements)

References 10 publications

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“…We anticipated that survival would steadily decrease with treatment duration as progression of disease and treatment complications added to cumulative mortality, as suggested previously [8]. However, we found that survival in fact increases in the first few days, peaking mid-week in the first week of treatment.…”

Section: Discussionsupporting

confidence: 66%

Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry

et al. 2017

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BackgroundVeno-arterial extracorporeal membrane oxygenation (VA ECMO) is an effective rescue therapy for severe cardiorespiratory failure, but morbidity and mortality are high. We hypothesised that survival decreases with longer VA ECMO treatment. We examined the Extracorporeal Life Support Organization (ELSO) registry for a relationship between VA ECMO duration and in-hospital mortality, and covariates including indication for support.MethodsAll VA runs from the ELSO database from 2002 to 2012 were extracted. Multiple runs and non-VA runs were excluded. Runs were categorized into diagnostic groups. Logistic regression for analysis of the effect of duration on outcome, and multivariate regression for diagnosis and other baseline factors were performed. Non-linear models including piecewise logistic models were fitted.ResultsThere were 2699 runs analysed over 14,747 days. Logistic regression analysis of the effect of duration on outcome, and multivariate regression analysis of diagnosis and other baseline factors were performed. In-hospital survival was 41.4% (95% CI 39.6–43.3). 75% of patients were supported for less than 1 week and 96% for less than 3 weeks. Median duration (4 days IQR 2.0–6.8) was greater in survivors (4.1 (IQR 2.5–6.7) vs 3.8 (IQR 1.7–7.0) p = 0.002). The final multivariate model demonstrated increasing survival to day 4 (OR 1.53 (95% CI 1.37–1.71) p < 0.001), decreasing from day 4 to 12 (OR 0.86 (95% CI 0.81–0.91), p < 0.001) with no significant change thereafter (OR 0.98 (95% CI 0.94–1.02), p = 0.400).ConclusionsECMO for 4 days or less is associated with higher mortality, likely reflecting early treatment failure. Survival is highest when patients are weaned on the fourth day of ECMO but likely decreases into the second week. While this does not suggest weaning at this point will produce better outcomes, it does reflect the likely time course of ECMO as a bridge in severe shock. Patients with some underlying conditions (like myocarditis and heart transplantation) achieve better outcomes despite longer support duration. These findings merit prospective study for the development of prognostic models and weaning strategies.

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Section: Discussionsupporting

confidence: 66%

Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry

et al. 2017

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“…Longer duration of ECMO support is associated with increased mortality in children after cardiac surgery 18. In our series, median ECMO duration was 12 (3.5–24) days and we observed an increased incidence of thrombotic complications.…”

Section: Discussionsupporting

confidence: 46%

Extracorporeal membrane oxygenation for neonatal collapse caused by enterovirus myocarditis

Cortina

Best

Deisenberg

et al. 2017

Arch Dis Child Fetal Neonatal Ed

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In this case series, ECMO initiation prevented further deterioration and cardiac arrest in neonates with severe EV myocarditis and not responding to conventional medical therapies. Moreover, complete cardiac recovery occurred in survivors. However, these neonates may need long ECMO runs and are at increased risk for mechanical complications. Furthermore, mortality remains high due to greater disease severity.

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“…Initially starting from 1970s, the usage of ECMO in pediatric cardiac surgery has gradually increased over the last 40 years (1,2). The most common indications for ECMO usage in postoperative pediatric cardiac cases are low cardiac output syndrome, pulmonary hypertension, inotropic refractory cardiogenic shock, inability to weaning from cardiopulmonary bypass, bridging to cardiac transplantation and extracorporeal cardiopulmonary resuscitation.…”

Section: Introductionmentioning

confidence: 99%

Utilization of Extracorporeal Membrane Oxygenation In Pediatric Cardiac Surgery: A Single Center Experience, 34 Cases in 8 Years

Zeybek

Avsar

Yildirim³

et al. 2017

Iran J Pediatr

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Background: Extracorporeal membrane oxygenation (ECMO) is used in a variety of indications worldwide. One of the most important subsets is postoperative congenital cardiac surgery cases unresponsive to conventional therapies. In this study, we present our ECMO experience in a single congenital cardiac surgery center. Methods: ECMO was used in a total of 34 postoperative congenital cardiac surgery cases, whose operations had been performed by the same congenital cardiac surgery team. Patients' ages were between 3 days to 15 years. ECMO was used in four different indications; in case of unsuccessful weaning from cardiopulmonary bypass (OR-ECMO), in low cardiac output syndrome (LCOS-ECMO), in refractory post cardiac arrest (CPR-ECMO) and in respiratory insufficiency after RSV infection (RSV-ECMO). Results: The follow-up period of patients ranged from 1 to 80 months, whereas ECMO duration ranged from 23 to 2218 hours. Six cases were OR-ECMO, 13 were LCOS-ECMO, 12 were CPR-ECMO and 3 were RSV-ECMO. Out of a total of 34 cases, 20 (58%) cases were weaned from ECMO. Two of the patients, who were able to be weaned from ECMO passed away in the hospital; however, the other 18 patients (52.9%) were discharged from the hospital without having any significant neurological deficits. The top survival rate (69%) and weaning from ECMO was in the LCOS-ECMO group and the worst weaning from ECMO support (33%) was in the RSV-ECMO. The worst survival rate (25%) was in the CPR-ECMO group. Sepsis and associated multiple organ dysfunction were observed as the major cause of mortality in these patients. The most common complications were bleeding and mechanical complications related to cannulation. Conclusions: ECMO may be required in postoperative congenital cardiac surgery cases in whom all other conventional therapies have failed. Indications, timing and maintenance of equipment are very important points in successful ECMO management. Increasing ECMO experience in the near future, will provide much decrease in mortality of congenital cardiac surgery.

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Impact of Timing of ECMO Initiation on Outcomes After Pediatric Heart Surgery: A Multi-Institutional Analysis

Cited by 44 publications

References 10 publications

Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry

Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry

Extracorporeal membrane oxygenation for neonatal collapse caused by enterovirus myocarditis

Utilization of Extracorporeal Membrane Oxygenation In Pediatric Cardiac Surgery: A Single Center Experience, 34 Cases in 8 Years

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