Survival and Neurocognitive Outcomes After Cardiac Extracorporeal Life Support in Children Less Than 5 Years of Age

Abstract

Background— Survival after pediatric cardiac extracorporeal life support (ECLS) is guarded, and neurological morbidity varies widely. Our objective is to report our 10-year experience with cardiac ECLS, including survival and kindergarten entry neurocognitive outcomes; to identify predictors of mortality or adverse neurocognitive outcomes; and to compare 2 eras, before and after 2005. Methods and Results— From 2000 to 2009, 98 children had venoarterial cardiac ECLS. Sixty-four patients (65%) survived to hospital discharge, and 50 (51%) survived ≤5 years of age. Neurocognitive follow-up of survivors was completed at mean (SD) age of 52.9 (8) months using Wechsler Preschool and Primary Scale of Intelligence. Logistic regression analysis found the longer time (hours) for lactate to fall below 2 mmol/L on ECLS (hazard ratio, 1.39; 95% confidence interval, 1.05, 1.84; P =0.022), and the amount of platelets (mL/kg) given in the first 48 hours (hazard ratio, 1.18; 95% confidence interval, 1.06, 1.32; P =0.002) was independently associated with higher in-hospital mortality. Receiving ECLS after the year 2005 was independently associated with lower risk of in-hospital mortality (hazard ratio, 0.36; 95% confidence interval, 0.13, 0.99; P =0.048). Extracorporeal cardiopulmonary resuscitation was not independently associated with mortality or neurocognitive outcomes. Era was not independently associated with neurocognitive outcomes. The full-scale intelligence quotient of survivors without chromosomal abnormalities was 79.7 (16.6) with 25% below 2 SD of the population mean. Conclusions— Mortality has improved over time; time for lactate to fall on ECLS and volume of platelets transfused are independent predictors of mortality. Extracorporeal cardiopulmonary resuscitation and era were not independently associated with neurocognitive outcomes.

Predictors and outcomes of early post-operative veno-arterial extracorporeal membrane oxygenation following infant cardiac surgery

“…After cardiac ECMO, neurologic outcomes with comprehensive follow-up suggest mental delay in 38% of survivors and no clear difference with E-CPR, but this is based on very small numbers [3]. Recently, the CPTFP reported a review of 10 years of cardiac ECMO in 98 patients and found 65% survival to hospital discharge, 51% survival to 5 years, full-scale intelligence quotient of survivors 79.7 (SD 16.6) with 25% below 2 SD of the population mean, and GAC of 79.2 (SD 19.4); E-CPR and location of cannulation (operating room vs. PCICU) were not associated with survival or neurocognitive outcomes [18]. Of interest, survival improved in the more recent era, and this was associated with lower lactate and inotrope scores prior to ECMO cannulation [18].…”

“…Recently, the CPTFP reported a review of 10 years of cardiac ECMO in 98 patients and found 65% survival to hospital discharge, 51% survival to 5 years, full-scale intelligence quotient of survivors 79.7 (SD 16.6) with 25% below 2 SD of the population mean, and GAC of 79.2 (SD 19.4); E-CPR and location of cannulation (operating room vs. PCICU) were not associated with survival or neurocognitive outcomes [18]. Of interest, survival improved in the more recent era, and this was associated with lower lactate and inotrope scores prior to ECMO cannulation [18]. In 51 cardiac patients having E-CPR, the CPTFP reported 49% survival to hospital discharge, 43% survival to 5 years, full-scale intelligence quotient of survivors 76.5 (SD 15.9), GAC of 74.5 (SD 20.3) with 47% having a score below 2 SD of the population mean, and 24% having both full-scale intelligence quotient and GAC below 2 SD of the population mean, similar findings to those of all cardiac ECMO cases in the 10-year review [19].…”

Supporting pediatric patients with short-term continuous-flow devices

“…STCF-VAD support permits time for decisions to be made about the potential for myocardial recovery and allows for a detailed assessment of end-organ function. ECMO is another option for short-term support for acute cardiopulmonary failure, but survival to hospital discharge remains a challenge, with reports of 32% to 73% in single centers studies [8][9][10][11][12][13] and 40% to 50% for pediatric cardiac ECMO from the Extracorporeal Life Support Organization (ELSO) registry. 14 We have shown from our experience that STCF-VADs are able to support 67% of children to hospital discharge, with successful long-term outcomes.…”

Improving Long-Term Outcomes After Extracorporeal Membrane Oxygenation: From Observational Follow-Up Programs Toward Risk Stratification

“…Of eight available studies on long-term neurological outcome in children who needed ECMO for cardiac failure, only four actually performed age-appropriate neuropsychiatric tests ( 73 ). The proportion of children available for follow-up ranged from 26-51% ( 73 ) and the cohorts overlap in two of these studies ( 91 , 92 ). In a Canadian study in four centers, 42 percent of the 98 children requiring VA-ECMO for cardiac disease were neonates and all 44 survivors without chromosomal abnormality were assessed at a mean age of 52 months.…”

“…In a Canadian study in four centers, 42 percent of the 98 children requiring VA-ECMO for cardiac disease were neonates and all 44 survivors without chromosomal abnormality were assessed at a mean age of 52 months. The mean IQ was 79.7, and 25% of children had an IQ below−2 SD ( 91 ). The same group reported on neurodevelopmental outcomes in a subset of 17 five-year-old ECPR survivors with cardiac disease who were assessed at least 6 months after ECPR.…”