Support with extracorporeal membrane oxygenation for over 1 year duration as a bridge to cardiac transplantation: a case report and review of the literature

Heart Transplantation in Patients Less Than 18 Years of Age: Comparison of 2 Eras Over 36 Years and 323 Transplants at a Single Institution

BACKGROUND

We reviewed our management strategy and outcome data for all 311 patients less than 18 years of age who underwent 323 heart transplants at our institution (1986 to 2022) in order to assess changes in patterns of practice and outcomes over time and to compare two consecutive eras: era 1 (154 heart transplants [1986 to 2010]) and era 2 (169 heart transplants [2011 to 2022]).

STUDY DESIGN

Descriptive comparisons between the two eras were performed at the level of the heart transplant for all 323 transplants. Kaplan-Meier survival analyses were performed at the level of the patient for all 311 patients, and log-rank tests were used to compare groups.

RESULTS

Transplants in era 2 were younger (6.6 ± 6.5 years vs 8.7 ± 6.1 years, p = 0.003). More transplants in era 2 were in infants (37.9% vs 17.5%, p < 0.0001), had congenital heart disease (53.8% vs 39.0%, p < 0.010), had high panel reactive antibody (32.1% vs 11.9%, p < 0.0001), were ABO-incompatible (11.2% vs 0.6%, p < 0.0001), had prior sternotomy (69.2% vs 39.0%, p < 0.0001), had prior Norwood (17.8% vs 0%, p < 0.0001), had prior Fontan (13.6% vs 0%, p < 0.0001), and were in patients supported with a ventricular assist device at the time of heart transplant (33.7% vs 9.1%, p < 0.0001). Survival at 1, 3, 5, and 10 years after transplant was as follows: era 1 = 82.4% (76.5 to 88.8), 76.9% (70.4 to 84.0), 70.7% (63.7 to 78.5), and 58.8% (51.3 to 67.4), respectively; era 2 = 90.3% (85.7 to 95.1), 85.4% (79.7 to 91.5), 83.0% (76.7 to 89.8), and 66.0% (49.0 to 88.8), respectively. Overall Kaplan-Meier survival in era 2 was better (log-rank p = 0.03).

CONCLUSIONS

Patients undergoing cardiac transplantation in the most recent era are higher risk but have better survival.

Necrotizing pneumonia requiring prolonged extracorporeal membrane oxygenation: Pushing the boundaries in pediatric ECMO

Extracorporeal membrane oxygenation (ECMO) is a life-saving rescue therapy used in acute respiratory failure refractory to invasive mechanical ventilation. Recent studies on positive outcomes of extended ECMO therapy are promising. We describe a case of a 2-year 8-month-old female child with necrotizing pneumonia secondary to Streptococcus pneumoniae, Influenza A, and Mycoplasma pneumoniae, who survived with intact neurological function and no long-term adverse outcomes after a prolonged ECMO run of 86 days. To the best of our knowledge, this is one of the longer durations of ECMO with transplant-free survival in a pediatric patient requiring respiratory support with good recovery and a good functional outcome. Allowing time for native lung recovery is pivotal for optimal recovery, despite significant lung injury due to the underlying disease process. With evolving ECMO experience, clinicians may need to re-consider the conventional maximum duration of ECMO in children with severe respiratory failure on a case-by-case basis.