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Ann Thorac Surg 1995;60:133-138
© 1995 The Society of Thoracic Surgeons
Departments of Cardiovascular Surgery, Critical Care Medicine, Cardiovascular Perfusion, and Cardiology, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario, Canada
Accepted for publication March 3, 1995.
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. Information was gathered on 31 consecutive children with myocardial failure who could not be resuscitated with other means and underwent ECMO at the Hospital for Sick Children before January 1994.
Results. Of the children who underwent ECMO as a means of cardiac rescue, 14/31 (45%) were weaned successfully. Two distinct groups of children were evident based on their initial indications for ECMO: those who had postcardiotomy myocardial dysfunction (n = 25) and those with cardiomyopathy or myocarditis (n = 6). Children with residual defects after cardiotomy (n = 10) did not survive ECMO. Four of the 6 children with cardiomyopathy or myocarditis were weaned successfully. In either group of patients ECMO support beyond 6 days failed to resuscitate the myocardium; all attempts to violate this ``time barrier'' in our study inevitably failed.
Conclusions. Postcardiotomy residual defects are a contraindication to ECMO. If children with residual defects are excluded, successful weaning from ECMO can be achieved in almost 70%, with almost all recovery occurring with the first 6 days of ECMO.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Recent reports on ECMO have examined its application as a means of cardiac rescue in children with severe myocardial dysfunction and as a bridge to transplantation. The objective of ECMO is to provide circulatory support for the period (short to intermediate) of myocardial dysfunction. At present, few functional pediatric mechanical support devices are available. We have adopted a biventricular mechanical support program although we are aware that univentricular assist devices may be used in selected children [1]. This biventricular philosophy originated from the observations that (1) myocarditis rarely is limited to one ventricle, (2) the ventricular septum frequently is involved in the pathologic process, with an eventual detrimental effect on both ventricles, (3) a significant number of children have right ventricular failure, making implementing mechanical support technically challenging, (4) hypoxemia frequently follows long, complicated corrective procedures or may be present before the initiation of ECMO, ie, total anomalous pulmonary venous drainage with obstruction, and (5) children do not tolerate right ventricular failure, either primary or secondary with the subsequent elevation of central venous pressures needed to optimize right ventricular output.
We thus report our results with venoarterial ECMO as a short-term support for children with myocardial failure. Our purpose is to determine possible predictors of successful salvage of children with severe myocardial dysfunction and the practical duration of ECMO support. If determinants for successful weaning can be ascertained, perhaps the excellent survival results found with use of ECMO in RDS patients can be achieved in pediatric cardiac patients.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Indications for ECMO Among the 31 Children
There were two main indications for initiating cardiac ECMO. The majority of children had myocardial failure (n = 28), with a smaller subset having respiratory failure with severe hypoxia after cardiopulmonary bypass (n = 3).
Statistical Analysis
Multivariate analysis including multiple linear regression and analysis of variance was performed using the following variables: patient's weight (kg), body surface area (m2), duration of ECMO support (days), sex, and anatomic diagnosis on admission. In children with postcardiotomy myocardial dysfunction, complete or incomplete surgical repair was an additional variable investigated. The dependent variable in the analysis was mortality.
For purposes of this study, a complete (surgical) repair was defined as the complete absence of hemodynamically significant residual defects. Intraoperative transesophageal echocardiography, pullback pressure measurements, and oxygen saturations were used to ascertain defects such as residual gradients, shunts, and other anatomic aberrations. Incomplete repairs required a further corrective procedure on cardiopulmonary bypass at the time of the first operation or during a second operation after an interval of attempted stabilization in the PICU.
Techniques for Cannulation
The optimal site for ECMO cannulation remains undetermined but likely dependent on the initial indications for ECMO, the size of the child, and experience of the surgeon. Morbidity secondary to site of cannulation is not inconsequential; therefore, the onus is on the surgeon to determine which site (chest, neck, or groin) should be chosen. Femoral cannulation was used for the initiation of cardiac ECMO in 3 children, whereas the remaining 28 had direct cardiac cannulation (left and right atria/aorta).
Schematic of The Hospital for Sick Children ECMO Circuit
The technical details of the centrifugal ECMO circuit used at The Hospital for Sick Children are illustrated below. Most recent changes not demonstrated include the insertion of a Carmeda (Medtronic, Anaheim, CA) treated circuit including the use of a Medtronic Minimax oxygenator/heat exchanger (Fig 1
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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. In total, only 14 of 31 children (45%) were weaned successfully from ECMO. However, when children with postcardiotomy residual defects were omitted from analysis (n = 10), success in weaning approached that of those requiring ECMO for RDS, ie, 4/6 (66%) with myocarditis or cardiomyopathy and 10/15 (66%) with postcardiotomy myocardial dysfunction.
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Techniques for Cannulation
Direct cardiac cannulation (right and left atria/aorta) via the median sternotomy (n = 28) offered several advantages, especially in the postcardiotomy patient. Excellent left-sided decompression was achieved by direct left atrial cannulation, avoiding atrial septostomy, which may be necessary with either the neck (not used in the cardiac population, only in those with RDS) or groin routes [1, 2]. Bleeding remained troublesome (up to 45 mL • kg-1 • min-1), even though several alternatives to heparin sulfate for anticoagulation are available. Early experience with the Carmeda circuit (n = 2) seems promising in reducing blood loss during ECMO support. Fibrinogen levels are well maintained while the patient remains well anticoagulated as based on activated thrombin times (activated thrombin times > 160 seconds, fibrinogen levels > 1.0 mg/dL).
Femoral artery and vein cannulation (n = 3) has one major advantage: cannulation simultaneous with closed/open chest compression in the event of a cardiac arrest. Bleeding was less troublesome as compared with direct cardiac cannulation. Three children in our series were cannulated by the femoral route. Concerns using this route in children relate to complications secondary to compartment syndrome (the femoral vein may require ligation in children and infants with small vessels), poor retroperfusion of the aortic arch with possible subsequent neurologic sequelae, and failure to decompress the left heart. To combat the compartment syndrome, we developed a modified ECMO circuit decompressing the distal limb by means of a ``saphenous vein sump.'' The first child had his proximal greater saphenous vein cannulated at the ankle after groin cannulation, whereas 2 subsequent children had distal saphenous vein cannulation at the time of groin cannulation (Fig 2).
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Tables 1 and 3 provide information about the 6 children diagnosed as having cardiomyopathy or myocarditis. Their clinical deterioration was acute, occurring over a period of 3 to 5 days, ultimately requiring urgent transfer to intensive care. Four of these children had a cardiac arrest, 3 in the PICU. Two children had profound low output syndrome that was unresponsive to maximal dosages of inotropic agents shortly after being admitted to the hospital. Although 4 children were weaned from ECMO, only 3 of the 6 children survived (1 child was bridged successfully to cardiac transplantation).
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Indications for ECMO in the Postcardiotomy Population
Indications for ECMO were subdivided as follows: myocardial dysfunction (corrected/residual lesions), respiratory support (hypoxia), and poor preoperative myocardial function with the likelihood of requiring postoperative ECMO. Tables 2 and 3 provide information on the 25 children diagnosed with postcardiotomy myocardial failure. For purposes of analysis, these patients were subdivided into those with complete or incomplete repairs.
MYOCARDIAL DYSFUNCTION (INCOMPLETELY CORRECTED LESIONS [N = 10]).
Of the 10 patients who died, all required ECMO because they could not be weaned successfully from cardiopulmonary bypass after the first attempt at surgical correction. Residual lesions that required a second corrective operation in these children are as follows: 2 residual ventricular septal defects, 4 cases of residual right ventricular outflow tract obstruction with and without pulmonary valvular regurgitation, 2 cases of residual left ventricular outflow tract obstruction, and 3 cases of residual left-sided atrioventricular valve regurgitation (atrioventricular septal defects).
MYOCARDIAL DYSFUNCTION (COMPLETELY CORRECTED LESIONS [N = 5]).
Five patients required ECMO because they could not be weaned successfully from cardiopulmonary bypass after surgical correction even with maximal dosages of inotropic agents. The surgical procedures in this subgroup of children were complex, left ventriculotomies being required in 2 children and extensive reconstruction of the left ventricular outflow tract in 1. There was no evidence of residual lesions either at the time of surgical intervention or retrospectively during review of chart data.
HYPOXEMIA (N = 3).
Of 3 children requiring ECMO for hypoxemia, 1 was diagnosed with total anomalous venous drainage and required ECMO until the postcapillary pulmonary venous hypertension resolved. A second child with tetralogy of Fallot had a preoperative diagnosis of bronchopulmonary dysplasia (the patient was diagnosed as a neonate and required home oxygen before surgical intervention). The third child had hypoxemia after cardiopulmonary bypass, and died of severe necrotizing pneumonitis proven at autopsy. All 3 patients required respiratory support for poor oxygenation in the midst of preserved myocardial function.
MYOCARDIAL DYSFUNCTION EVIDENCED ON PREOPERATIVE PRESENTATION (N = 7).
Seven children made up this select group of patients in whom anticipation for postoperative ECMO was confirmed. Anomalous origin of the left coronary artery was diagnosed in 4 children, each demonstrating echocardiographic evidence of severe preoperative myocardial dysfunction (ejection fractions of 0.10 to 0.20). One of these 4 children suffered a cardiac arrest due to ventricular dysrrhymias in the PICU, thus requiring ECMO. Other pediatric conditions with severe preoperative myocardial dysfunction included (1 child in each group): critical aortic stenosis, total anomalous venous drainage, and surgically corrected atrioventricular septal defect with concomitant coarctation of the aorta (no postoperative functional valvular abnormalities).
Morbidity in Patients With Cardiomyopathy or Myocarditis
Of the 6 children who were placed on ECMO, 2 children suffered neurologic complications eventually leading to death. Both children made full cardiac recovery. One child with severe disseminated intravascular coagulopathy suffered a severe intracranial hemorrhage after being weaned successfully. The other had no evidence of brainstem function and died when support including ECMO was removed because of multiorgan failure (severe hepatic and neurologic dysfunction). Two children, the latter child included, had clinical and biochemical evidence of multiorgan failure (renal and hepatic) requiring dialysis before their deaths. Of the 3 children successfully weaned and discharged from the hospital, no child had long-term sequelae, ie, either hepatic or renal failure from ECMO.
Morbidity in the Postcardiotomy Patients
Of the 10 children who were placed on ECMO after cardiotomy and were weaned successfully, only 1 child suffered long-term neurologic dysfunction. One year after his operation (anomalous origin of the left coronary artery with subsequent arrest in the PICU) his neurologic status has improved but continues to be abnormal. No survivor has demonstrated long-term renal or hepatic damage secondary to ECMO.
COMPLETELY CORRECTED LESIONS.
Of the 5 children who eventually died (33% of completely corrected children or 16.1% of all ECMO children), 2 children had atrioventricular septal defects: 1 with necrotizing pneumonitis and the other with concomitant severe mitral valve pathology. Two additional children who died had left ventriculotomies for unusual cardiac anatomy. The fifth patient, who was transferred to our institution after 5 days of ECMO support for meconium aspiration, required repair of total anomalous pulmonary venous drainage, for which diagnosis had been delayed.
INCOMPLETELY CORRECTED LESIONS.
All children who were placed on ECMO while harboring residual lesions died. One child with a residual lesion had complete correction only after a second operative procedure but before initiation of ECMO. He survived and is included in the ``completely corrected'' category.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Medical literature continues to support the belief that cardiac arrest in children is associated with a poor survival rate [6, 7] and that only a small percentage of cardiac patients can be weaned from ECMO. However, of more than 1,000 children registered with the North American ELSO registry, 40% survived [7–9]. Our study provides evidence to support the use of ECMO in selected children. Overall, 45% of children treated in our institution were weaned successfully. If the children with residual cardiac defects are excluded, the survival rate improves to 67%. Cardiac rescue using ECMO in selected children now can approximate the excellent survival results obtained for children with RDS.
The arbitrary division of congenital lesions according to anatomy has become customary in ECMO literature. Certain conditions continue to show poor overall results with ECMO as a mode of postcardiotomy cardiac salvage (ELSO Registry data) (Table 4). The ELSO Registry data are based strictly on an anatomic and physiologic diagnosis. Our data suggest that the presence of residual hemodynamic abnormalities precludes survival. Therefore, categorization of patients with regard to eligibility for ECMO should be based on the presence or absence of such defects. Complete surgical repair should be a prerequisite for instituting ECMO. Intraoperative studies, ie, transesophogeal echocardiography, should be performed before ECMO salvage is contemplated. Only children with potentially reversible myocardial injury who cannot be weaned from cardiopulmonary bypass should be considered eligible for ECMO as short- to intermediate-term circulatory support. A cardiotomy child similar to those reported by del Nido and associates [10] required ECMO after cardiac arrest. This patient underwent repair of an anomalous origin of the left coronary artery and suffered postoperative dysrrhythmias requiring cardiopulmonary resuscitation after unsuccessful ventricular defibrillation. In a selected group of children with complex lesions or unfavorable anatomy, cardiac transplantation rather than repair should be considered the primary treatment option. Our data on ECMO as a bridge to transplantation is limited to only 1 patient; however, her survival despite an initial cardiac arrest in the PICU is encouraging [4, 8, 9, 11–13].
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Any child with myocarditis or cardiomyopathy may be considered a candidate for ECMO, even with cardiac arrest if it occurs in the PICU (rather than on the surgical ward or outside of hospital) at the initial presentation [4, 11, 13, 14]. Extracorporeal membrane oxygenation support is not advised when the cardiac arrest occurs outside the operating room or the PICU, unless the child can be resuscitated and transferred to the PICU where intact neurologic function can be demonstrated (may be difficult to substantiate).
The maximum time required for recovery for cardiotomy patients and those with myocarditis in this study was 6 days. Although our experience suggests that prolongation of ECMO beyond that period appears futile, others have reported recovery from acute myocarditis after mechanical support beyond 1 week [15]. The 2 patients in our series who seem to be the ``exception'' required additional ECMO support (days 7 and 8) to optimize respiratory function in the midst of full myocardial recovery based on previous weaning attempts with objective ejection fractions estimated from transesophageal echocardiography. We believe that initial recovery can be seen in the first 48 hours of ECMO support, although we lack objective proof at this time. This early period of myocardial recovery may play an important role in that ECMO support beyond this limit could be only justified as a ``bridge to transplantation.''
In summary, children with severe myocardial dysfunction have limited therapeutic options if they need mechanical support. Extracorporeal membrane oxygenation continues to be satisfactory for short - to intermediate-term mechanical support, either for eventual myocardial salvage (within 6 days) or as a bridge to transplantation if longer periods of support are required. Although the indications for ECMO continue to evolve, our data suggest that patient selection should exclude all children with postcardiotomy residual cardiac defects. The exclusion of those with residual cardiac defects should be incorporated into the strictly anatomic classification of those children who have undergone ECMO largely represented in the current literature. Support of cardiac ECMO programs should be encouraged, because the likelihood of successful weaning now approaches 70% in selected children. Many of these ECMO survivors would have died without this aggressive mode of cardiac support. Our experience is consistent with other reports in suggesting that recovery after postcardiotomy myocardial dysfunction is within 6 days as evidenced by transesophageal echocardiography and that prolonging ECMO beyond this may be futile, except as a bridge to transplantation. Exceptions to the ``6-day rule'' may exist. Concerns of premature termination of mechanical support therefore must be tempered with what has been achieved with myocardial recovery during the first 6 days.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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