Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2—pediatric patients

https://doi.org/10.1016/j.healun.2019.07.004Get rights and content

Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, veno-venous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure.

Section snippets

Trends in ECMO use

Utilization of PC-ECMO is variable among institutions performing surgery for CHD. Differences in ECMO utilization may reflect variation in technical performance, chosen operative interventions as well as ECMO availability, local indications for use, and the cost of ECMO. Before 1990, several authors reported that 1.5%–13% of children who underwent cardiac surgery for CHD were supported with ECMO (Table 1).13, 17, 18, 19 Using data from the Pediatric Health Information System, which contains

Survival and duration of ECMO support

After PC-ECMO, survival to hospital discharge ranges from 40% to 60% in most studies of pediatric patients (Table 3). Many factors influence the duration of PC-ECMO support in children, including the underlying cardiac lesion, presence of residual lesion, the family's wishes, cardiac surgical recovery time, and the applicability of bridging to transplant if recovery does not occur. Thus, the number of hours of PC-ECMO support varies greatly among different studies, ranging from 17 to more than

Complications of PC-ECMO in pediatric patients

Important complications of PC-ECMO in children and neonates include bleeding, mechanical complications, liver failure, sepsis, central nervous system events, and renal failure, which are reported at different rates in various studies (Table 4).17, 33, 50 Mechanical complications of ECMO are also common.33

Neurologic sequelae occur frequently in children supported with ECMO. In a study of 90 patients by Chow and colleagues,51 only 15 children survived without neurologic sequelae. There were

Post-cardiotomy V-V ECMO for respiratory dysfunction in pediatric patients

Despite advances in CPB techniques and in preventive measures aimed at decreasing respiratory complications after cardiac surgery, post-operative acute respiratory distress syndrome occurs in 1%–20% of patients, depending on inclusion criteria.56, 57, 58, 59 The use of V-A ECMO for refractory cardiovascular dysfunction after pediatric cardiac surgery has been described, but there is paucity of data on the use of post-cardiotomy V-V ECMO. Respiratory distress and hypoxia are reported as

Cardiac catherization during PC-ECMO

Diagnostic or therapeutic cardiac catheterization can be performed safely on patients receiving ECMO support.60 Early detection and correction of residual cardiac lesions is associated with improved survival.16, 61 Catheter-based diagnostic procedures should be considered when non-invasive diagnostic studies fail to identify a reason for failure to wean from ECMO and also to evaluate decompression of the left side of the heart.62 Callahan and colleagues reported the results of cardiac

Limitations of the review

Pediatric PC-ECMO, particularly in the setting of CHD, is a technically challenging but potentially life-saving mode of support. There is limited evidence to inform clinical practice. We acknowledge several limitations to the current systematic review that are inherent to retrospective, observational studies. First, most of the studies assembled here are single-center case series reports, precluding statistical analyses and lacking the power to detect some clinically significant differences in

Conclusion

V-A ECMO is the optimal support technique in children with CHD and post-cardiotomy shock. ECMO facilitates augmented cardiac output and respiratory gas exchange to improve the metabolic status of both pre-operative and post-cardiotomy patients. Although PC-ECMO can improve survival of this vulnerable population, mortality and morbidity remain high. Complications related to bleeding, thrombosis, and infections increase mortality and are major areas for improvement. Neurological injury and

Disclosure statement

R.L. is a consultant and conducts clinical trials for LivaNova (London, UK). D.B. is currently the co-chair of the Trial Steering Committee for the VENT-AVOID trial sponsored by ALung Technologies; he was previously on the medical advisory board of ALung Technologies and Kadence (Johnson & Johnson). All compensation for these activities is paid to Columbia University. The other authors have no conflicts of interest to disclose.

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