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Desai KD, Yuan I, Padiyath A, Goldsmith MP, Tsui FC, Pratap JN, Nelson O, Simpao AF. A Narrative Review of Multiinstitutional Data Registries of Pediatric Congenital Heart Disease in Pediatric Cardiac Anesthesia and Critical Care Medicine. J Cardiothorac Vasc Anesth 2023; 37:461-470. [PMID: 36529633 DOI: 10.1053/j.jvca.2022.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
Congenital heart disease (CHD) is one of the most common birth anomalies. While the care of children with CHD has improved over recent decades, children with CHD who undergo general anesthesia remain at increased risk for morbidity and mortality. Electronic health record systems have enabled institutions to combine data on the management and outcomes of children with CHD in multicenter registries. The application of descriptive analytics methods to these data can improve clinicians' understanding and care of children with CHD. This narrative review covers efforts to leverage multicenter data registries relevant to pediatric cardiac anesthesia and critical care to improve the care of children with CHD.
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Affiliation(s)
- Krupa D Desai
- Department of Anesthesiology, Perioperative Care, and Pain Medicine at NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Ian Yuan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Asif Padiyath
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Michael P Goldsmith
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Fu-Chiang Tsui
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jayant Nick Pratap
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Olivia Nelson
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Allan F Simpao
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Amodeo A, Stojanovic M, Dave H, Cesnjevar R, Konetzka A, Erdil T, Kretschmar O, Schweiger M. Bridging with Veno-Arterial Extracorporeal Membrane Oxygenation in Children: A 10-Year Single-Center Experience. Life (Basel) 2022; 12:life12091398. [PMID: 36143434 PMCID: PMC9503544 DOI: 10.3390/life12091398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is frequently used in children with and without congenital heart disease (CHD). This study, of a single-center and retrospective design, evaluated the use and timing of V-A ECMO in a pediatric cohort who underwent V-A ECMO implantation between January 2009 and December 2019. The patients were divided into a pre-/non-surgical group and a post-surgical group. Among the investigated variables were age, gender, weight, duration of ECMO, ECMO indication, and ventricular physiology, with only the latter being statistically relevant between the two groups. A total of 111 children (58 male/53 female), with a median age of 87 days (IQR: 7–623) were supported using V-A ECMO. The pre-/non-surgical group consisted of 59 patients and the post-surgical group of 52 patients. Survival at discharge was 49% for the pre-/non-surgical group and 21% for the surgical group (p = 0.04). Single-ventricle physiology was significant for a worse outcome (p = 0.0193). Heart anatomy still has the biggest role in the outcomes of children on ECMO. Nevertheless, children with CHD can be successfully bridged with ECMO to cardiac operation.
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Affiliation(s)
- Antonio Amodeo
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Correspondence:
| | - Milena Stojanovic
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Hitendu Dave
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Robert Cesnjevar
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Alexander Konetzka
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Tugba Erdil
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Oliver Kretschmar
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
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Bakoš M, Braovac D, Barić H, Belina D, Željko Đurić, Dilber D, Novak M, Matić T. Extracorporeal membrane oxygenation in children: An update of a single tertiary center 11-Year experience from Croatia. Perfusion 2022:2676591221093204. [PMID: 35543369 DOI: 10.1177/02676591221093204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is an important treatment option for organ support in respiratory insufficiency, cardiac failure, or as an advanced tool for cardiopulmonary resuscitation. Reports on pediatric ECMO use in our region are lacking. METHODS This study is a retrospective review of all pediatric cases that underwent a veno-arterial (VA) or veno-venous (VV) ECMO protocol between November 2009 and August 2020 at the Department of Pediatrics, University Hospital Center Zagreb, Croatia. RESULTS Fifty-two ECMO runs identified over the period; data were complete for 45 cases, of which 23 (51%) were female, and median age was 8 months. Thirty-eight (84%) patients were treated using the VA-and 7 (16%) using VV-ECMO. The overall survival rate was 51%. Circulatory failure was the most common indication for ECMO (N = 38, 84%), and in 17 patients ECMO was started after cardiopulmonary resuscitation (E-CPR). Among survivors, 74% had no or minor neurological sequelae. Variables associated with poor outcome were renal failure with renal replacement therapy (p < .001) and intracranial injury (p < .001). CONCLUSION Overall survival rate in our cohort is comparable to the data published in the literature. The use of hemodialysis was shown to be associated with higher mortality. High rates of full neurological recovery among survivors are a strong case for further ECMO program development in our institution.
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Affiliation(s)
- Matija Bakoš
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia
| | - Duje Braovac
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia
| | - Hrvoje Barić
- Department of Neurosurgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dražen Belina
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Željko Đurić
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Daniel Dilber
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Milivoj Novak
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Toni Matić
- Department of Pediatrics, University Hospital Centre Zagreb,Zagreb, Croatia.,School of Medicine, University of Zagreb, Zagreb, Croatia
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Bourgoin P, Aubert L, Joram N, Launay E, Beuchee A, Roue JM, Baruteau A, Fernandez M, Pavy C, Baron O, Flamant C, Liet JM, Ozanne B, Chenouard A. Frequency of Extracorporeal Membrane Oxygenation Support and Outcomes After Implementation of a Structured PICU Network in Neonates and Children: A Prospective Population-Based Study in the West of France. Pediatr Crit Care Med 2021; 22:e558-e570. [PMID: 33950889 DOI: 10.1097/pcc.0000000000002748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the frequency and outcomes on the use of extracorporeal membrane oxygenation (ECMO) among critically ill neonates and children within a structured pediatric critical care network in the West of France. To assess the optimality of decision-making process for patients primarily admitted in non-ECMO centers. DESIGN Observational prospective population-based study from January 2015 to December 2019. PATIENTS Neonates over 34 weeks of gestational age, weighing more than 2,000 g and children under 15 years and 3 months old admitted in one of the 10 units belonging to a Regional Pediatric Critical Care Network. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eight-thousand one hundred eighty-nine children and 3,947 newborns were admitted within one of the 10 units of the network over the study period. Sixty-five children (8.1% [95% CI, 6.2-10‰]) and 35 newborns (9.4% [95% CI, 6.4-12%]) required ECMO support. Of these patients, 31 were first admitted to a non-ECMO center, where 20 were cannulated in situ (outside the regional ECMO center) and 11 after transfer to the ECMO regional center. Cardiogenic shock, highest serum lactate level, and cardiac arrest prior to first phone call with the regional ECMO center were associated with higher rate of in situ cannulation. During the study period, most of the patients were cannulated for underlying cardiac issue (42/100), postoperative cardiac surgery instability (38/100), and pediatric (10/100) and neonatal (10/100) respiratory distress syndrome. Patients primarily admitted in non-ECMO centers or not had similar 28-day post-ICU survival rates compared with those admitted in the referral ECMO center (58% vs 51%; p = 0.332). Pre-ECMO cardiac arrest, ECMO, and lower pH at ECMO onset were associated with lower 28-day post-ICU survival. CONCLUSIONS Our local results suggest that a structured referral network for neonatal and pediatric ECMO in the region of Western France facilitated escalation of care with noninferior (or similar) early mortality outcome. Our data support establishing referral networks in other equivalent regions.
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Affiliation(s)
- Pierre Bourgoin
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
- Department of Anesthesiology, University Hospital, Nantes, France
| | - Lucie Aubert
- Department of Pediatrics, University Hospital, Rennes, France
| | - Nicolas Joram
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Elise Launay
- Department of Pediatrics, University Hospital, Nantes, France
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Centre of Research in Epidemiology and StatisticS (CRESS), University of Paris, Paris, France
| | - Alain Beuchee
- Department of Pediatrics, Neonatal Intensive Care Unit, University Hospital, Rennes, France
| | - Jean Michel Roue
- Neonatal and Pediatric Intensive Care Unit, University Hospital, Brest, France
| | - Alban Baruteau
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Modesto Fernandez
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
- Department of Anesthesiology, University Hospital, Nantes, France
| | - Carine Pavy
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Olivier Baron
- Department of Pediatric Cardiology and Congenital Cardiac Surgery, University Hospital, Nantes, France
| | - Cyril Flamant
- Department of Pediatrics, Neonatal Intensive Care Unit, University Hospital, Nantes, France
| | - Jean Michel Liet
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Bruno Ozanne
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Rennes, France
| | - Alexis Chenouard
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital, Nantes, France
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Abuharb MYI, Ran D, Jubing Z, Taoshuai L, Haiming D, Xiaotong H, Yue S, Yang Z, Yang L. Surgical outcomes in cardiogenic shock patients with preoperative extracorporeal membrane oxygenation (ECMO). J Cardiothorac Surg 2021; 16:214. [PMID: 34344398 PMCID: PMC8329613 DOI: 10.1186/s13019-021-01542-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/19/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives To summarise the surgical outcomes in patients with cardiogenic shock supported by preoperative extracorporeal membrane oxygenation (ECMO). Methods Between May 2012 and August 2017, eight patients with cardiogenic shock, who were supported by ECMO, underwent emergency surgery; four of them had isolated coronary artery bypass grafting, three had coronary artery bypass grafting with mitral replacement, and one had mitral valve replacement with left ventricular posterior wall repair. Results All eight patients were successfully weaned off from ECMO after their surgeries. Postoperative ECMO time ranged from 6.8 to 228.0 h, with a median of 68.4 h. Two patients died postoperatively while another six survived. The follow up time for the six patients ranged from three to 66 months, whereby one of them died in the third month due to septicaemia. The remaining five patients survived with good cardiac function based on the NYHA classification. Conclusion ECMO is a vital bridge in the preparation of critically-ill patients for cardiac surgery. It is associated with acceptable outcomes among most of the patients.
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Affiliation(s)
- Mahmoud Yousef Ibrahim Abuharb
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China
| | - Dong Ran
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China.
| | - Zheng Jubing
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China.
| | - Liu Taoshuai
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China
| | - Dong Haiming
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China
| | - Hou Xiaotong
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China
| | - Song Yue
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China
| | - Zhao Yang
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China
| | - Li Yang
- Cardiovascular Surgery Department, Capital Medical University Affiliated Anzhen Hospital, Aiguo Road, Lianhe Avenue, Beijing, 100029, China
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Melvan JN, Davis J, Heard M, Trivedi JR, Wolf M, Kanter KR, Deshpande SR, Alsoufi B. Factors Associated With Survival Following Extracorporeal Cardiopulmonary Resuscitation in Children. World J Pediatr Congenit Heart Surg 2021; 11:265-274. [PMID: 32294013 DOI: 10.1177/2150135120902102] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We examined a large single-institution experience in extracorporeal cardiopulmonary resuscitation (ECPR) in children having cardiac arrest refractory to conventional resuscitation measures with focus on factors affecting survival. METHODS Between 2002 and 2017, 184 children underwent ECPR at our institution. We entered demographic, anatomic, clinical, surgical, and ECPR support details into a multivariable logistic regression models to determine factors associated with mortality. RESULTS Median age was 54 days (interquartile range [IQR]: 11-272). In all, 157 (85%) patients had primary cardiac disease, including 136 (74%) with congenital heart disease (71 with single ventricle). Extracorporeal cardiopulmonary resuscitation occurred following cardiac surgery in 124 (67%) patients. Median cardiopulmonary resuscitation (CPR) duration was 27 minutes (IQR: 18-40) and median support duration was 3.0 days (IQR: 1.6-5.3). Overall, ECPR was weaned in 115 (63%), with 79 (43%) surviving to hospital discharge. Survival for patients with congenital heart disease, noncongenital cardiac, and noncardiac pathologies was 44%, 71%, and 15%, respectively. On multivariable regression analysis, risk factors associated with mortality were presupport pH <7.1 (odds ratio [OR] = 3.7, 95% confidence interval [CI]: 1.11-12.41, P = .033), mechanical complications (OR = 8.33, 95% CI: 1.91-36.25, P = .005), neurologic complications (OR = 6.27, 95% CI: 1.40-28.10, P = .017), and renal replacement therapy (OR = 3.31, 95% CI: 1.03-10.66, P = .045). CONCLUSIONS Extracorporeal cardiopulmonary resuscitation plays a valuable role salvaging children with refractory cardiac arrest. Survival varies with underlying pathology and can be expected even with relatively longer CPR durations. Efforts to improve systemic output before and after institution of ECPR might mitigate some of the significant risk factors for mortality.
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Affiliation(s)
- John Nicholas Melvan
- Division of Cardiothoracic Surgery, Children Healthcare of Atlanta, Emory University, GA, USA
| | - Joel Davis
- Division of Pediatric Cardiology, Children Healthcare of Atlanta, Emory University, GA, USA
| | - Micheal Heard
- Division of Pediatric Cardiology, Children Healthcare of Atlanta, Emory University, GA, USA
| | - Jaimin R Trivedi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Michael Wolf
- Division of Pediatric Cardiology, Children Healthcare of Atlanta, Emory University, GA, USA
| | - Kirk R Kanter
- Division of Cardiothoracic Surgery, Children Healthcare of Atlanta, Emory University, GA, USA
| | - Shriprasad R Deshpande
- Division of Pediatric Cardiology, Children Healthcare of Atlanta, Emory University, GA, USA
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
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Heneghan JA, Ramakrishnan K, Wernovsky G. Type C Esophageal Atresia and d-Transposition of the Great Arteries in a Newborn. World J Pediatr Congenit Heart Surg 2021; 11:652-653. [PMID: 32853061 DOI: 10.1177/2150135120928961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A newborn was diagnosed with type C esophageal atresia and d-transposition of the great arteries (d-TGA). In this report, we discuss the management implications of the co-occurrence of two rare congenital abnormalities, including extracorporeal membrane oxygenation support prior to surgical intervention for d-TGA.
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Affiliation(s)
- Julia A Heneghan
- Division of Critical Care Medicine, Department of Pediatrics, 233494Children's National Hospital and the George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Karthik Ramakrishnan
- Division of Cardiac Surgery, Department of Pediatrics, 43989Children's National Hospital and the George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Gil Wernovsky
- Divisions of Cardiac Critical Care Medicine and Pediatric Cardiology, Department of Pediatrics, Children's National Hospital and the George Washington School of Medicine and Health Sciences, Washington, DC, USA. Heneghan is now with the Division of Critical Care Medicine, Department of Pediatrics, 311816University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
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Hospital-Acquired Infection in Pediatric Subjects With Congenital Heart Disease Postcardiotomy Supported on Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:e1020-e1025. [PMID: 32590829 DOI: 10.1097/pcc.0000000000002409] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine prevalence of and risk factors for infection in pediatric subjects with congenital heart disease status postcardiotomy supported on extracorporeal membrane oxygenation, as well as outcomes of these subjects. DESIGN Retrospective cohort from the Extracorporeal Life Support Organization. SETTING U.S. and international medical centers providing care to children with congenital heart disease status postcardiotomy. PATIENTS Critically ill pediatric subjects less than 8 years old admitted to medical centers between January 1, 2013, and December 31, 2015, who underwent cardiac surgery for congenital heart disease and required extracorporeal membrane oxygenation support within the first 14 postoperative days. Subjects were excluded if they underwent orthotopic heart transplantation, required preoperative extracorporeal membrane oxygenation, and had more than one postoperative extracorporeal membrane oxygenation run. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 1,314 extracorporeal membrane oxygenation subject encounters in the Extracorporeal Life Support Organization registry met inclusion criteria. Neonates comprised 53% (n = 696) of the cohort, whereas infants made up 33% (n = 435). Of the 994 subjects with Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery categorizable surgery, 33% (n = 325) were in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 and 23% (n = 231) in Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 5. While on extracorporeal membrane oxygenation, 229 subjects (17%) acquired one or more extracorporeal membrane oxygenation-related infections, which represents an occurrence rate of 67 infections per 1,000 extracorporeal membrane oxygenation days. Gram-negative (62%) and Gram-positive (42%) infections occurred most commonly. Forty percent had positive blood cultures. Infants and children were at higher infection risk compared with neonatal subjects; subjects undergoing less complex surgery had higher infection rates. Unadjusted survival to hospital discharge was lower in infected subjects compared with noninfected subjects (43% vs 51%; p = 0.01). After adjusting for confounders via propensity matching, we identified no significant mortality difference between infected and noninfected subjects. CONCLUSIONS Neonatal and pediatric subjects in this study have a high rate of acquired infection. Infants and children were at higher infection risk compared with neonatal subjects. There was not, however, a significant association between extracorporeal membrane oxygenation-related infection and survival to hospital discharge after propensity matching.
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Mirabile C, Malekzadeh-Milani S, Bojan M, Raisky O, Gaudin R, Bonnet D, Boudjemline Y. A case series of transcatheter Potts Shunt creation in a pediatric population affected with refractory pulmonary artery hypertension: focus on the role of ECMO. Perfusion 2020; 36:415-420. [PMID: 32880213 DOI: 10.1177/0267659120954169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE Patients with suprasystemic idiopathic pulmonary hypertension (S-PAH) have a poor prognosis. Therapeutic options are limited. Reverse Potts shunt creation modifies physiology transforming patients with PAH into Eisenmenger physiology with a better outcome. Percutaneous transcatheter stent secured aortopulmonary connection (transcatheter Potts Shunt, TPS) is a feasible very high-risk procedural option in such patients. We report our experience with patients undergoing TPS at our institution requiring extracorporeal membrane oxygenation (ECMO) support. METHODS A prospective observational study of patients with drug-refractory PAH, worsening NYHA class, and right ventricular failure undergoing TPS. Two patients required rescue ECMO for cardiac arrest during the procedure. Subsequently, "standby ECMO" was available in all the following cases and elective support was provided in patients with extremely poor conditions. RESULTS Ten pediatric patients, underwent TPS at our institution. Two patients were rescued by ECMO after cardiac arrest during the shunt creation. This occurred as a result of the acute loading of the left ventricle (LV) after retrograde aortic arch filling through the Potts shunt. Following this, another two patients underwent elective ECMO after the uneventful induction of anesthesia. They all died postoperatively despite a successful TPS procedure. The causes of death were not related to the use of ECMO, but the complication of severe PAH. Six patients with successful TPS did not require ECMO and survived. CONCLUSIONS TPS is a pioneering procedure offering the opportunity to treat high-risk idiopathic drug-refractory PAH patients. Acute LV failure is a complication of TPS in patients with S-PAH. Elective ECMO, an option to avoid circulatory arrest and acute profound hypoxia secondary to exclusive right-to left shunt systemic perfusion by Potts shunt and LV dysfunction with resulting pulmonary edema, may be used at the early stage of the learning curve, but it does not influence the prognosis of these patients which remains poor.
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Affiliation(s)
- Cristian Mirabile
- Department of Anesthesiology and Critical Care, Marie Lannelongue Hospital, Paris, France
| | | | - Mirela Bojan
- Department of Anesthesiology and Critical Care, Marie Lannelongue Hospital, Paris, France
| | - Olivier Raisky
- Pediatric Cardiac Surgery, Necker-Enfants Malades University Hospital, Paris, Île-de-France, France
| | - Regis Gaudin
- Pediatric Cardiac Surgery, Necker-Enfants Malades University Hospital, Paris, Île-de-France, France
| | - Damien Bonnet
- Pediatric Cardiology, Necker-Enfants Malades University Hospital, Paris, Île-de-France, France
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Straube T, Cheifetz IM, Jackson KW. Extracorporeal Membrane Oxygenation for Hemodynamic Support. Clin Perinatol 2020; 47:671-684. [PMID: 32713457 DOI: 10.1016/j.clp.2020.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Extracorporeal membrane oxygenation was first successfully achieved in 1975 in a neonate with meconium aspiration. Neonatal extracorporeal membrane oxygenation has expanded to include hemodynamic support in cardiovascular collapse before and after cardiac surgery, medical heart disease, and rescue therapy for cardiac arrest. Advances in pump technology, circuit biocompatibility, and oxygenators efficiency have allowed extracorporeal membrane oxygenation to support neonates with increasingly complex pathophysiology. Contraindications include extreme prematurity, extremely low birth weight, lethal chromosomal abnormalities, uncontrollable hemorrhage, uncontrollable disseminated intravascular coagulopathy, and severe irreversible brain injury. The future will involve collaboration to guide and evolve evidence-based practices for this life-sustaining therapy.
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Affiliation(s)
- Tobias Straube
- Pediatric Critical Care Medicine, Duke Children's, Durham, NC, USA
| | - Ira M Cheifetz
- Pediatric Critical Care Medicine, Duke Children's, Durham, NC, USA
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Factors affecting the outcome of extracorporeal membrane oxygenation following paediatric cardiac surgery. Cardiol Young 2019; 29:1501-1509. [PMID: 31744582 DOI: 10.1017/s1047951119002634] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation has been widely used after paediatric cardiac surgery due to increasing complex surgical repairs in neonates and infants having complex CHDs. MATERIALS AND METHODS We reviewed retrospectively the medical records of all patients with CHD requiring corrective or palliative cardiac surgery at King Abdulaziz University Hospital that needed extracorporeal membrane oxygenation support between November 2015 and November 2018. RESULTS The extracorporeal membrane oxygenation population was 30 patients, which represented 4% of 746 children who had cardiac surgery during this period. The patients' age range was from 1 day to 20.33 years, with a median age of 6.5 months. Median weight was 5 kg (range from 2 to 53 kg). Twenty patients were successfully decannulated (66.67%), and 12 patients (40%) were survived to hospital discharge. Patients with biventricular repair tended to have better survival rate compared with those with single ventricle palliation (55.55 versus 16.66%, p-value 0.058). During the first 24 hours of extracorporeal membrane oxygenation support, the flow rate was significantly reduced after 4 hours of extracorporeal membrane oxygenation connection in successfully decannulated patients. CONCLUSION Survival to hospital discharge in patients requiring extracorporeal membrane oxygenation support after paediatric cardiac surgery was better in those who underwent biventricular repair than in those who had univentricular palliation. Capillary leak on extracorporeal membrane oxygenation could be a risk of mortality in patients after paediatric cardiac surgery.
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12
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Bautista-Hernandez V, Avila-Alvarez A, Marx GR, Del Nido PJ. [Current surgical options and outcomes for newborns with hypoplastic left heart syndrome]. An Pediatr (Barc) 2019; 91:352.e1-352.e9. [PMID: 31694800 DOI: 10.1016/j.anpedi.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 09/09/2019] [Indexed: 02/02/2023] Open
Abstract
Since the first successful palliation was performed by Norwood et al. in 1983, there have been substantial changes in diagnosis, management, and outcomes of hypoplastic left heart syndrome, Survival for stage 1 palliation has increased to 90% in many centres, with patients potentially surviving into adulthood. However, the associated morbidity and mortality remain substantial. Although the principles of staged surgical palliation of hypoplastic left heart syndrome are well established, there is significant variability in surgical procedure and management between centres, and several controversial aspects remain unresolved. In this review, we summarize the current surgical and management options for newborns with hypoplastic left heart syndrome and their outcomes.
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Affiliation(s)
- Victor Bautista-Hernandez
- Servicio de Cirugía Cardiovascular, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España; Cardiopatía Estructural y Congénita, Instituto de Investigación Biomédica A Coruña (INIBIC), A Coruña, España.
| | - Alejandro Avila-Alvarez
- Cardiopatía Estructural y Congénita, Instituto de Investigación Biomédica A Coruña (INIBIC), A Coruña, España; Unidad de Neonatología, Servicio de Pediatría, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, España
| | - Gerald R Marx
- Servicio de Cardiología, Boston Children'S Hospital/Harvard Medical School, Boston, Estados Unidos
| | - Pedro J Del Nido
- Servicio de Cirugía Cardíaca, Boston Children's Hospital/Harvard Medical School, Boston, Estados Unidos
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Current surgical options and outcomes for newborns with hypoplastic left heart syndrome. An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Lorusso R, Raffa GM, Kowalewski M, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Dalton H, Barbaro R, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, Oreto L, D'Alessandro DA, Boeken U, Whitman G. Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2-pediatric patients. J Heart Lung Transplant 2019; 38:1144-1161. [PMID: 31421976 DOI: 10.1016/j.healun.2019.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 06/19/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022] Open
Abstract
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.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy.
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Khalid Alenizy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Niels Sluijpers
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maged Makhoul
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Brodie
- Division of Pulmonary & Critical Care Medicine, Columbia University, New York, New York
| | - Mike McMullan
- Cardiac Surgery Unit, Seattle Children Hospital, Seattle, Washington
| | - I-Wen Wang
- Cardiac Transplantation and Mechanical Circulatory Support Unit, Indiana University School of Medicine, Health Methodist Hospital, Indianapolis, Indiana
| | - Paolo Meani
- Heart & Vascular Centre, Cardiology Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University of Singapore, Singapore
| | - Heidi Dalton
- INOVA Fairfax Medical Centre, Adult and Pediatric ECMO Service, Falls Church, Virginia
| | - Ryan Barbaro
- Division of Pediatric Critical Care and Child Health Evaluation and Research Unit, Ann Arbor, Michigan
| | - Xaotong Hou
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nicholas Cavarocchi
- Surgical Cardiac Care Unit, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Ped Cardiovascular Surgery, National Taiwan University Hospital, Taipei, China
| | - Ravi Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
| | - Peta Alexander
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lilia Oreto
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Pediatric Hospital, Taormina, Messina, Italy
| | - David A D'Alessandro
- Cardio-Thoracic Surgery Department, Massachusetts Medical Center, Boston, Massachusetts
| | - Udo Boeken
- Cardiovascular Surgery Unit, University of Düsseldorf, Düsseldorf, Germany
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit and Heart Transplant, Johns Hopkins Hospital, Baltimore, Maryland
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Aguilar JM, Garcia E, Melo M, Rojas C, Belda S, Llorente A, Garcia-Maellas M, Boni L. Oxigenación por membrana extracorpórea poscardiotomía en la edad pediátrica: 119 pacientes en 20 años de experiencia. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Brunetti MA, Gaynor JW, Retzloff LB, Lehrich JL, Banerjee M, Amula V, Bailly D, Klugman D, Koch J, Lasa J, Pasquali SK, Gaies M. Characteristics, Risk Factors, and Outcomes of Extracorporeal Membrane Oxygenation Use in Pediatric Cardiac ICUs: A Report From the Pediatric Cardiac Critical Care Consortium Registry. Pediatr Crit Care Med 2018; 19:544-552. [PMID: 29863638 PMCID: PMC6051408 DOI: 10.1097/pcc.0000000000001571] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cardiopulmonary failure in children with cardiac disease differs from the general pediatric critical care population, yet the epidemiology of extracorporeal membrane oxygenation support in cardiac ICUs has not been described. We aimed to characterize extracorporeal membrane oxygenation utilization and outcomes across surgical and medical patients in pediatric cardiac ICUs. DESIGN Retrospective analysis of the Pediatric Cardiac Critical Care Consortium registry to describe extracorporeal membrane oxygenation frequency and outcomes. Within strata of medical and surgical hospitalizations, we identified risk factors associated with extracorporeal membrane oxygenation use through multivariate logistic regression. SETTING Tertiary-care children's hospitals. PATIENTS Neonates through adults with cardiac disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 14,526 eligible hospitalizations from August 1, 2014, to June 30, 2016; 449 (3.1%) included at least one extracorporeal membrane oxygenation run. Extracorporeal membrane oxygenation was used in 329 surgical (3.5%) and 120 medical (2.4%) hospitalizations. Systemic circulatory failure and extracorporeal cardiopulmonary resuscitation were the most common extracorporeal membrane oxygenation indications. In the surgical group, risk factors associated with postoperative extracorporeal membrane oxygenation use included younger age, extracardiac anomalies, preoperative comorbidity, higher Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery category, bypass time, postoperative mechanical ventilation, and arrhythmias (all p < 0.05). Bleeding requiring reoperation (25%) was the most common extracorporeal membrane oxygenation complication in the surgical group. In the medical group, risk factors associated with extracorporeal membrane oxygenation use included acute heart failure and higher Vasoactive Inotropic Score at cardiac ICU admission (both p < 0.0001). Stroke (15%) and renal failure (15%) were the most common extracorporeal membrane oxygenation complications in the medical group. Hospital mortality was 49% in the surgical group and 63% in the medical group; mortality rates for hospitalizations including extracorporeal cardiopulmonary resuscitation were 50% and 83%, respectively. CONCLUSIONS This is the first multicenter study describing extracorporeal membrane oxygenation use and outcomes specific to the cardiac ICU and inclusive of surgical and medical cardiac disease. Mortality remains high, highlighting the importance of identifying levers to improve care. These data provide benchmarks for hospitals to assess their outcomes in extracorporeal membrane oxygenation patients and identify unique high-risk subgroups to target for quality initiatives.
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Affiliation(s)
- Marissa A Brunetti
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - J William Gaynor
- Department of Surgery, The Cardiac Center, The Children's Hospital of Philadelphia & Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lauren B Retzloff
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Jessica L Lehrich
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health & Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Venugopal Amula
- Department of Pediatrics, Primary Children's Hospital & University of Utah School of Medicine, Salt Lake City, UT
| | - David Bailly
- Department of Pediatrics, Primary Children's Hospital & University of Utah School of Medicine, Salt Lake City, UT
| | - Darren Klugman
- Department of Pediatrics, Children's National Medical Center & George Washington University School of Medicine, Washington, DC
| | - Josh Koch
- Department of Pediatrics, Children's Medical Center & University of Texas Southwestern Medical Center, Dallas, TX
| | - Javier Lasa
- Department of Pediatrics, Texas Children's Hospital & Baylor College of Medicine, Houston, TX
| | - Sara K Pasquali
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Michael Gaies
- Department of Pediatrics, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Abstract
This review article will discuss the indications for and outcomes of neonates with congenital heart disease who receive extracorporeal membrane oxygenation (ECMO) support. Most commonly, ECMO is used as a perioperative bridge to recovery or temporary support for those after cardiac arrest or near arrest in patients with congenital or acquired heart disease. What had historically been considered a contraindication to ECMO, is evolving and more of the sickest and most complicated babies are cared for on ECMO. Given that, it is imperative for aggressive survellience for long-term morbidity in survivors, particularly neurodevelopmental outcomes.
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Affiliation(s)
- Kiona Y Allen
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 21, 225 E Chicago Ave, Chicago, IL 60610.
| | - Catherine K Allan
- Department of Cardiology, Harvard Medical School Boston Children's Hospital, Boston, MA
| | - Lillian Su
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Mary E McBride
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Box 21, 225 E Chicago Ave, Chicago, IL 60610
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19
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Khorsandi M, Davidson M, Bouamra O, McLean A, MacArthur K, Torrance I, Wylie G, Peng E, Danton M. Extracorporeal membrane oxygenation in pediatric cardiac surgery: A retrospective review of trends and outcomes in Scotland. Ann Pediatr Cardiol 2018; 11:3-11. [PMID: 29440824 PMCID: PMC5803974 DOI: 10.4103/apc.apc_88_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Around 3.2%–8.4% of patients receive venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support after pediatric cardiac surgery. The desired outcome is “bridge-to-recovery” in most cases. There is no universally agreed protocol, and given the associated costs and complications rates, the decisions as of when and when not to institute VA ECMO are largely empirical. Methods: A retrospective review of the ECMO database at the Scottish Pediatric Cardiac Services (SPCS) was undertaken. Inclusion criterion encompassed all children (<16 years of age) who were supported with VA ECMO following cardiac surgery between January 2011 and October 2016. The timing of ECMO support was divided into three distinct phases: “endofcase” or intheatre ECMO for patients unable to effectively wean from cardiopulmonary bypass (CPB), ECMO for cardiopulmonary resuscitation (“ECPR”), and Intensive Care Unit ECMO for “failing maximal medial therapy” following cardiac surgery. The patients were analyzed to identify survival rates, adverse prognostic indicators, and complication rates. Results: We identified 66 patients who met the inclusion criterion. 30day survival rate was 45% and survival rate to hospital discharge was 44% (the difference represents one patient). On followup (median: 960 days, range: 42–2010 days), all survivors to hospital discharge were alive at review date. “End-of-case” ECMO showed a trend toward better survival of the three subcategories (“end of case,” ECPR, and ECMO for “failing maximal medical therapy” survival rates were 47%, 41%, and 37.5%, respectively, P = 0.807). The poorest survival rates were in the younger children (<6 months, P = 0.502), patients who had prolonged CPB (P = 0.314) and aortic crossclamp times (P = 0.146), and longer duration of ECMO (>10 days, P = 0.177). Conclusions: Allcomers VA ECMO following pediatric cardiac surgery had survival to discharge rate of 44%. Elective “end-of-case” ECMO carries better survival rates and therefore ECMO instituted early maybe advantageous. Prolonged ECMO support has a direct correlation with mortality.
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Affiliation(s)
- Maziar Khorsandi
- Department of Cardiac Surgery, Royal Hospital for Children, Glasgow, UK
| | - Mark Davidson
- Department of Critical Care Medicine, Royal Hospital for Children, Glasgow, UK
| | - Omar Bouamra
- Department of Medical Statistics, Trauma, Audit and Research Network, University of Manchester, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Andrew McLean
- Department of Cardiac Surgery, Royal Hospital for Children, Glasgow, UK
| | - Kenneth MacArthur
- Department of Cardiac Surgery, Royal Hospital for Children, Glasgow, UK
| | - Ida Torrance
- Department of Cardiac Surgery, Royal Hospital for Children, Glasgow, UK
| | - Gillian Wylie
- Department of Critical Care Medicine, Royal Hospital for Children, Glasgow, UK
| | - Ed Peng
- Department of Cardiac Surgery, Royal Hospital for Children, Glasgow, UK
| | - Mark Danton
- Department of Cardiac Surgery, Royal Hospital for Children, Glasgow, UK
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20
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Metrics to Assess Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Surgery Programs. Pediatr Crit Care Med 2017; 18:779-786. [PMID: 28498231 DOI: 10.1097/pcc.0000000000001205] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Only a small fraction of pediatric cardiac surgical patients are supported with extracorporeal membrane oxygenation following cardiac surgery, but extracorporeal membrane oxygenation use is more common among those undergoing higher complexity surgery. We evaluated extracorporeal membrane oxygenation metrics indexed to annual cardiac surgical volume to better understand extracorporeal membrane oxygenation use among U.S. cardiac surgical programs. DESIGN Retrospective analysis SETTING:: Forty-three U.S. Children's Hospitals in the Pediatric Health Information System that performed cardiac surgery and used extracorporeal membrane oxygenation. PATIENTS All patients (< 19 yr) undergoing cardiac surgery during January 2003 to July 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Both extracorporeal membrane oxygenation use and surgical mortality were risk adjusted using Risk Adjustment for Congenital Heart Surgery 1. Extracorporeal membrane oxygenation metrics indexed to annual cardiac surgery cases were calculated for each hospital and the metric values divided into quintiles for comparison across hospitals. Among 131,786 cardiac surgical patients, 3,782 (2.9%) received extracorporeal membrane oxygenation. Median case mix adjusted rate of extracorporeal membrane oxygenation use was 2.8% (interquartile range, 1.6-3.4%). Median pediatric cardiac case mix adjusted surgical mortality was 3.5%. Extracorporeal membrane oxygenation-associated surgical mortality was 1.3% (interquartile range, 0.7-1.6%); without extracorporeal membrane oxygenation, median case mix adjusted surgical mortality would increase from 3.5% to 5.0%. Among patients who died, 36.7% (median) were supported with extracorporeal membrane oxygenation. The median reduction in case mix adjusted surgical mortality from extracorporeal membrane oxygenation surgical survival was 30.1%. The median extracorporeal membrane oxygenation free surgical survival was 95% (interquartile range, 94-96%). Centers with less than 150 annual surgical cases had significantly lower median extracorporeal membrane oxygenation use (0.78%) than centers with greater than 275 cases (≥ 2.8% extracorporeal membrane oxygenation use). Extracorporeal membrane oxygenation use and mortality varied within quintiles and across quintiles of center annual surgical case volume. CONCLUSIONS Risk adjusted extracorporeal membrane oxygenation metrics indexed to annual surgical volume provide potential for benchmarking as well as a greater understanding of extracorporeal membrane oxygenation utilization, efficacy, and impact on cardiac surgery mortality.
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Eschenbach LK, Kasnar-Samprec J, Ackermann K, Schreiber C, Lange R, Cleuziou J. Preoperative Venovenous ECMO in an Infant With Late Diagnosis of Hypoplastic Left Heart Syndrome. World J Pediatr Congenit Heart Surg 2017; 11:NP41-NP43. [PMID: 28677480 DOI: 10.1177/2150135117697228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Late diagnosis and late referral for the Norwood stage 1 procedure in patients with hypoplastic left heart syndrome is rare and associated with a higher mortality. We present a case of a cyanotic almost five-week-old infant with hypoplastic left heart syndrome, highly restrictive foramen ovale, and patent ductus arteriosus, who was bridged with venovenous extracorporeal membrane oxygenation to the Norwood stage 1 procedure.
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Affiliation(s)
- Lena K Eschenbach
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jelena Kasnar-Samprec
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Kilian Ackermann
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Christian Schreiber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Rudiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julie Cleuziou
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
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22
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Cashen K, Hollis TK, Delius RE, Meert KL. Extracorporeal membrane oxygenation for pediatric cardiac failure: Review with a focus on unique subgroups. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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23
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Gupta P, Robertson MJ, Beam BW, Rettiganti M. Outcomes associated with preoperative use of extracorporeal membrane oxygenation in children undergoing heart operation for congenital heart disease: a multi-institutional analysis. Clin Cardiol 2014; 38:99-105. [PMID: 25545610 DOI: 10.1002/clc.22358] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/10/2014] [Accepted: 10/18/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND There are very sparse data on patient outcomes related to the use of extracorporeal membrane oxygenation (ECMO) prior to heart operation in children with congenital heart disease. This study was designed to evaluate this association using the Pediatric Health Information System (PHIS) database. HYPOTHESIS We hypothesize that patients receiving ECMO prior to heart operation will have worse outcomes, including mortality, compared with patients receiving ECMO after heart operation. METHODS Patients age ≤18 years receiving ECMO before or after pediatric heart operation (with or without cardiopulmonary bypass) at a PHIS-participating hospital from 2004 to 2013 were included. Multivariable logistic regression or Cox proportional-hazards models were fitted to study the effect of timing of ECMO initiation in relation to cardiac surgery on study outcomes. RESULTS A total of 3498 patients from 42 hospitals qualified for inclusion. Of these, 494 (14%) received ECMO prior to heart operation (presurgery ECMO) and 3004 (86%) received ECMO after heart operation (postsurgery ECMO). Unadjusted mortality was significantly lower in the presurgery ECMO group compared with the postsurgery ECMO group (30% vs 45%; P < 0.0001). After adjusting for patient and center characteristics, odds of mortality were significantly lower in the presurgery ECMO group (odds ratio: 0.46, 95% confidence interval: 0.36-0.59, P < 0.0001). There were no significant differences in ECMO duration, length of hospital stay, and hospital charges between the 2 groups in adjusted models. CONCLUSIONS This study suggests that ECMO can be used with satisfactory outcomes prior to heart operation in children with congenital heart disease.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Cardiology, Little Rock, Arkansas
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Uilkema RJ, Otterspoor LC. Extracorporeal membrane oxygenation in adult patients with congenital heart disease. Neth Heart J 2014; 22:520-2. [PMID: 24522953 PMCID: PMC4391172 DOI: 10.1007/s12471-014-0526-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- R J Uilkema
- Division Vital Functions, Intensive Care Centre, University Medical Centre, Utrecht, the Netherlands
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25
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Aguirre J, Mavroudis C, Jacobs M, Stewart R. Direct operating room triage of neonates with total anomalous pulmonary venous connection. Pediatr Cardiol 2014; 34:1874-6. [PMID: 22797519 DOI: 10.1007/s00246-012-0426-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/25/2012] [Indexed: 10/28/2022]
Abstract
Total anomalous pulmonary venous connection with obstruction constitutes a surgical emergency. Medical therapy is palliative and unlikely to result in significant or sustained physiologic improvement. Two cases demonstrate the successful use of a novel management scheme in which patients are admitted directly to the operating room for diagnosis confirmation and treatment, obviating the need for time-consuming preoperative assessment in an intensive care unit before surgery.
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Affiliation(s)
- Jason Aguirre
- Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH, 44106, USA
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26
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Mesher AL, McMullan DM. Extracorporeal life support for the neonatal cardiac patient: outcomes and new directions. Semin Perinatol 2014; 38:97-103. [PMID: 24580765 DOI: 10.1053/j.semperi.2013.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Extracorporeal life support is an important therapy for neonates with life-threatening cardiopulmonary failure. Utilization of extracorporeal life support in neonates with congenital heart disease has increased dramatically during the past three decades. Despite increased usage, overall survival in these patients has changed very little and extracorporeal life support-related morbidity, including bleeding, neurologic injury, and renal failure, remains a major problem. Although survival is lower and neurologic complications are higher in premature infants than term infants, cardiac extracorporeal life support including extracorporeal cardiopulmonary resuscitation is effective in preventing death in many of these high-risk patients. Miniaturized ventricular assist devices and compact integrated extracorporeal life support systems are being developed to provide additional therapeutic options for neonates.
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Affiliation(s)
- Andrew L Mesher
- Department of Surgery, University of Washington School of Medicine, Seattle, WA
| | - David Michael McMullan
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, WA; Department of Surgery, University of Washington School of Medicine, Seattle, WA.
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Pediatric outcomes after extracorporeal membrane oxygenation for cardiac disease and for cardiac arrest: a review. ASAIO J 2012; 58:297-310. [PMID: 22643323 DOI: 10.1097/mat.0b013e31825a21ff] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
We reviewed reported survival and neurological outcomes, and predictors of these outcomes for pediatric cardiac extracorporeal membrane oxygenation (ECMO) and extracorporeal cardiopulmonary resuscitation (ECPR). We searched PubMed from 2000 to April 2011. Cumulative survival after cardiac ECMO in children was 788/1755 (45%); renal dysfunction, dialysis, neurologic complication, lactate, and ECMO duration consistently predicted this outcome, whereas single ventricle and ECPR did not. Neurological outcomes after cardiac ECMO were based on poorly described telephone questions in two studies for 47 patients with 51% significantly impaired and detailed follow-up testing for 42 patients in three studies with mental delay in 38% and mental score >85 (average or above) in 33%. Cumulative survival after ECPR in children was 371/762 (49%); noncardiac disease, renal dysfunction, neurologic complication, and pH on extracorporeal life support consistently predicted this outcome, whereas duration of CPR did not. Neurological outcomes after ECPR were based predominantly on the pediatric cerebral performance category (PCPC) score by chart review, with 161/181 (79%) having PCPC <2. No study reported detailed follow-up testing for survivors of ECPR. Survival outcomes of most cardiac subgroups were similar, except for concerning mortality in cavopulmonary connection patients. Priority areas for study include identification of potentially modifiable predictors of long-term outcomes.
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Perioperative care of the infant with single ventricle physiology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 13:444-55. [PMID: 21671164 DOI: 10.1007/s11936-011-0134-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OPINION STATEMENT Among patients with congenital heart defects, neonates with single ventricle disease continue to challenge clinicians despite significant improvements in survival over the past 30 years. The cardiac anatomical variants associated with the term "single ventricle" are characterized by severe hypoplasia (or absence) of either ventricle, typically in association with obstruction or atresia of either the pulmonary or systemic outflow tracts. Physiologically, the single ventricle receives both pulmonary and systemic venous blood and ejects simultaneously into the pulmonary and systemic circulations, a pattern commonly referred to as single ventricle physiology. Medical and surgical management strategies, though palliative, are aimed at achieving the optimal balance of systemic blood flow and pulmonary blood flow to maximize oxygen delivery. Patients with single ventricle physiology have a greater risk of dying than those with biventricular circulations and are generally committed to multiple palliative interventions throughout childhood with considerable risk. Surgical intervention in the newborn period involves Norwood Stage I palliation, placement of a systemic-to-pulmonary artery shunt, or banding of the pulmonary artery, depending on the status of the outflow tracts. Heart transplantation is offered as the initial approach in some centers. The management strategy and the actual delivery of care from the time of birth (or at time of diagnosis) through the postoperative period is crucial to optimize the short-term and long-term outcomes. Whereas survival following initial palliation in experienced centers is as high as 95%, emphasis is now appropriately shifting toward the control of in-hospital morbidity and optimizing long-term functional outcome. Centers are continually striving to gather and apply new knowledge related to the underlying anatomical and physiologic problems while seeking to improve decision making and care of the patient with single ventricle physiology.
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Perioperative mechanical circulatory support in children with critical heart disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2011; 13:414-24. [PMID: 21748290 DOI: 10.1007/s11936-011-0140-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OPINION STATEMENT The treatment of cardiovascular failure in the perioperative period with the use of mechanical circulatory support is a well-recognized, well-developed, and commonly utilized treatment modality. Regardless of the exact circumstances of initiation, the use of a support device is a "bridge." Where there has been an acute myocardial insult, short-term assist devices can serve as a "bridge to immediate survival," a "bridge to recovery," or even a "bridge to the next decision." Mechanical circulatory support can serve as a treatment of cardiovascular decompensation caused by myocarditis, acute myocardial insult, low cardiac output following surgery, and congenital heart disease. The utilization of such support carries significant risks such as bleeding, infection, and thrombosis. However, these can be minimized in order to allow for the safe and effective deployment of this therapeutic strategy. One specific therapeutic domain in which these devices provide immediate impact is during cardiac arrest. Although outcomes of cardiac arrest remain poor, use of a mechanical device as an intervention has allowed salvage of otherwise certain mortality. However, it is important to note that the utility of support was most pronounced in patients that were not on either extreme of the survival prediction curve. This can be best summarized by the concept of "not too early, not too late." Therefore, it is the responsibility of the entire care team to find the appropriate patient population in which to "pull the trigger" on mechanical support as a therapy. This decision point is supported by a monitoring strategy that can be utilized to predict deterioration and intervene adequately. Most importantly, an effective monitoring strategy allows the practitioner to judge the effectiveness of treatment and support strategies and make adjustments in a timely manner, potentially with mechanical support in the perioperative period.
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Vasavada R, Feng Qiu, Ündar A. Current status of pediatric/neonatal extracorporeal life support: clinical outcomes, circuit evolution, and translational research. Perfusion 2011; 26:294-301. [DOI: 10.1177/0267659111401673] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal life support (ECLS) offers lifesaving mechanical circulatory support for patients afflicted with respiratory and/or cardiac failure. Neonatal respiratory patients have higher survival rates compared to pediatric patients, while, for cardiac cases, pediatric patients are more likely to survive. The indications for ECLS have been expanded due to the improved technology and favorable outcomes. However, the rate of mortality and morbidity for ECLS patients remains significant. Mechanical complications still comprise a large percentage of ECLS complications, leaving definite room for improvement in ECLS circuit technology in the future. As a pre-clinical evaluating tool, translational research will provide more useful information for the selection of ECLS devices, encourage further development of ECLS technology, and, ultimately, benefit the patients.
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Affiliation(s)
- Rahul Vasavada
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA
| | - Feng Qiu
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA, Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA, Department of Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State Hershey
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Susheel Kumar TK, Sinha P, Moulick A, Jonas RA. Risks of extracorporeal membrane oxygenation in patients with coronary artery anomalies. World J Pediatr Congenit Heart Surg 2010; 1:249-53. [PMID: 23804829 DOI: 10.1177/2150135110372528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal membrane oxygenation is widely used to support and rest the heart before or following repair of congenital cardiac lesions in children. The beneficial effects of extracorporeal membrane oxygenation for the failing myocardium are undisputed. It is often an automatic choice whenever the heart seems incapable of supporting the circulation. However, its use may prove detrimental in patients with coronary anomalies, as illustrated by the case reports presented here.
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Affiliation(s)
- T K Susheel Kumar
- Children's National Medical Center, Cardiac Surgery, Washington, DC, USA
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