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Ann Thorac Surg 1996;61:336-339
© 1996 The Society of Thoracic Surgeons

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ECMO for Cardiac Support

Extracorporeal Membrane Oxygenation for Cardiac Support in Children

Department of Cardiac Surgery, Harvard Medical School, and Children's Hospital, Boston, Massachusetts

Abstract

Background. Extracorporeal membrane oxygenation (ECMO) support for cardiac failure has been used in children since 1981 at the Children's Hospital in Pittsburgh. Most children required support after cardiac operations. Recently, however, a larger number of patients with decompensated cardiomyopathy or myocarditis have been supported with ECMO, which was used as a bridge to transplantation in most.

Methods. From 1981 to 1994, 68 children were placed on ECMO for cardiac support.

Results. The overall survival for the entire time period was 38%, with the more recent experience survival increased to 47%. In 14 children, ECMO was used as a bridge to transplantation, with 9 children receiving a heart transplant and 7 long-term survivors. Extracorporeal membrane oxygenation has also been used to resuscitate 11 children after sudden cardiac arrest, with a long-term survival of 53%.

Conclusions. We conclude that ECMO support for severe cardiac failure is effective. Patient selection and the use of heart transplantation for intractable heart failure have improved the overall survival.

Circulatory support in children with severe cardiac failure is still most commonly achieved by the use of an extracorporeal membrane oxygenator (ECMO) circuit [1]. Although there are an increasing number of reports describing the experience with circulatory support using other systems such as centrifugal pumps or pneumatic assist devices [2–6], ECMO circuits remain the more commonly used method of support in this age group. This is most likely due to the ready availability of ECMO circuits and the necessary support staff in most pediatric centers.

In the Extracorporeal Life Support Organization Registry, there have been an increasing number of children receiving circulatory support with ECMO after cardiotomy or for cardiac support in the last 5 years [7]. More recently the numbers have leveled at about 200 children per year reported to the Registry. Of these 200, the majority were placed on ECMO after cardiotomy. This number represents a small percentage of the pediatric surgical patient population, which has been estimated at approximately 25,000 to 30,000 open heart procedures per year in the United States, according to the American Heart Association statistics. With an overall mortality for this group ranging from 3% to 7%, approximately 1,000 to 2,000 children die yearly after cardiac operations. In addition to the postcardiotomy patients, a growing number of children are placed on ECMO for acute decompensation of chronic cardiomyopathy, or for a viral myocarditis where mechanical support is used as a bridge to transplantation.

This report will update the previously reported experience with ECMO support for severe cardiac failure in children at the Children's Hospital of Pittsburgh [8–10].

Material and Methods

Techniques of Support
Several types of devices have been used for mechanical circulatory support of children including full cardiopulmonary support with an ECMO circuit and ventricular assist devices, usually with a centrifugal pump for left or biventricular support. At The Children's Hospital of Pittsburgh since 1982 we have primarily used an ECMO circuit for circulatory support in children with severe cardiac failure. In infants with a body weight of less than 7 kg, a -inch tubing circuit with a roller head for a pump and a bladder box to regulate flow has been used. In children weighing more than 7 kg a -inch venous line with a Bio-Medicus centrifugal pump (Bio-Medicus Co, Eden Prairie, MN) using a pediatric pump head has been used [8]. This latter circuit permits a wider range of pump flows, which is required to accommodate the varied weight range in children. A membrane oxygenator (Avecor Cardiovascular, Inc, Plymouth, MN) was used in nearly all cases except where a heparin-coated circuit (Carmeda, Medtronic Co, Minneapolis, MN) was initially employed. Recently, in patients requiring support immediately after a cardiotomy, a heparin-bonded circuit including a hollow-fiber oxygenator has been used during the initial few hours of cardiac support. Minimal systemic heparinization was employed until mediastinal bleeding was well controlled; subsequently, anticoagulation to activated clotting times of 180 to 200 seconds was instituted. At this point the oxygenator was changed to a membrane type used for routine ECMO support.

Cannulation Techniques
In children, methods of cannulation for cardiopulmonary bypass vary greatly. For ECMO support, the most common method is venoarterial perfusion via the neck vessels. In children requiring support after a cardiotomy, cannulation was usually done through the sternotomy, with cannulas inserted directly into the aorta and right atrium and exteriorized at the bottom of the sternal skin incision. Neck cannulation in the postcardiotomy patients may still be preferable, however, particularly if there has been a period of time between cardiotomy and the need for ECMO support. This is due to the high incidence of mediastinal bleeding with transsternal cannulation and the need to redissect mediastinal structures. When direct decompression of the left ventricle was required due to distention, then transsternal cannulation with an additional vent cannula was the preferred method. In children supported on ECMO for cardiomyopathy where no sternotomy had been done, a blade atrial septostomy with balloon dilation was used to decompress the left atrium.

The cannulas most frequently used for cannulation via neck vessels were thin-wall wire-reinforced ECMO cannulas (Bio-Medicus Co) (Fig 1). For transsternal cannulation, the venous cannula was a metal angled cannula (DLP, Inc, Grand Rapids, MI) inserted through the right atrial appendage. The advantage of the thin-walled armored or metal cannulas is that the effective internal diameter is larger for the same outside diameter, and therefore flow is greatly improved.

View larger version (25K): [in this window] [in a new window]   Fig 1. . Cannulation via neck vessels for venoarterial extracorporeal membrane oxygenator support.

Results

Survival Rates With ECMO Support
Meliones and associates [7] in 1991 summarized the Extracorporeal Life Support Organization Registry data up to that time with ECMO for cardiac support, detailing the results with 189 children. The overall survival was about 43% for children with severe cardiac failure. Of the children supported on ECMO as a bridge to heart transplantation, survival was even worse with only 35% successfully receiving a heart transplant and leaving the hospital. The risk factors identified in that study were (1) cardiac arrest, either at the time or just before cannulation, (2) bleeding, (3) renal failure, and (4) prolonged intubation before ECMO support.

Since that report, many more patients have been added to the Extracorporeal Life Support Organization Registry; however, the overall results have not changed significantly. Overall survival for cardiac support remains at 46%, and in the subset of patients who failed to be weaned from bypass, the overall survival was significantly worse at 33%. Reports from individual centers where ECMO has been used for more than 5 years demonstrate a general trend toward higher survival rates in cardiac patients, but overall survival is only 50% to 55% when all children with cardiac failure are included.

At the Children's Hospital in Pittsburgh, since the ECMO program began in 1982 to October 1994, 68 children have been placed on ECMO support for cardiac failure with an overall survival rate of 38% (Table 1). The majority of these patients were more than 1 month of age, with a survival rate of 42% in this group versus 27% in 7 infants less than 1 month of age. There were no detectable differences in survival between children requiring support after cardiac operations versus children with decompensated cardiomyopathy or viral myocarditis. There were, however, some subsets of patients who did have a higher survival rate and merit more detailed discussion.

Of the 14 children accepted as candidates for transplantation, 8 had postcardiotomy contractile failure, 3 had acute decompensation of chronic dilated cardiomyopathy, and 3 had viral myocarditis with acute onset of severe cardiac failure. Five of these children had cardiac arrest and were placed on support during cardiopulmonary resuscitation. Duration of ECMO support was 109 ± 20 hours. Nine of 14 received a heart transplant, 1 child recovered spontaneously (myocarditis), and 4 died of sepsis on ECMO. Of the children who received transplants, 6 were early survivors with one late death (lymphoproliferative disease) for a total of 7 of 14 (50%) early and 6 of 14 (43%) late survivors.

Based on this experience we concluded that ECMO is an effective means of circulatory support as a bridge to transplantation in children. Decompression of the left ventricle is often required to prevent pulmonary edema. Sepsis and bleeding, however, remain a limitation to prolonged mechanical support with ECMO. The longest survivor in this group received 10 days of ECMO support.

Complications that occurred in this patient group included pulmonary edema, bleeding, and sepsis. The most common complication was pulmonary edema, occurring in 8 of the 14 children. The pulmonary edema was treated with continuous positive-pressure ventilation and decompression of the left ventricle. In children cannulated through neck vessels, a blade septostomy was done through a femoral catheter, and in those where direct access to the heart was available, a left ventricular vent was inserted. Four children had development of uncontrollable gram-negative septicemia requiring discontinuation of support and died. Bleeding requiring transfusion of red blood cells and clotting factors was seen in most patients. The average blood transfusion requirement was 57 mL•kg^-1•day^-1 of packed red blood cells. Platelets and plasma transfusions were also required in this patient group.

One child had significant aortic insufficiency requiring aortic valve closure on ECMO to improve systemic perfusion. This child did eventually receive a heart transplant and is one of our long-term survivors.

ECMO Support for Resuscitation From Cardiac Arrest
Sudden unexpected cardiac arrest after an open heart operation or in children with severe cardiac dysfunction from cardiomyopathy or myocarditis can occur in a small percentage of patients. Conventional methods for resuscitation including open chest cardiac massage may not be sufficient to reestablish cardiac function. Since 1987, ECMO has been used to support children after cardiac arrest unresponsive to conventional closed or open chest cardiac massage. Eleven children required ECMO support for resuscitation. The criteria used for determining which patients to place on mechanical support included (1) witnessed arrest, (2) rapid institution of cardiopulmonary resuscitation, (3) no recovery of cardiac function within 20 minutes of the initiation of cardiopulmonary resuscitation, and (4) no contraindication to mechanical support such as sepsis, preexisting severe neurologic deficit, or renal failure.

Of the 11 children supported on ECMO there were 7 early survivors (64%) with one late death (>1 month) for an overall survival of 55% long term (see Table 1). The mean duration of cardiopulmonary resuscitation before the start of ECMO support was 65 ± 9 minutes, and the average length of ECMO support was 112 ± 18 hours. In 3 children support was discontinued due to severe neurologic injury, and 1 child required heart transplantation for severe cardiac dysfunction.

Comment

Although survival rates have improved with ECMO support for severe cardiac failure, the overall goal of long-term support remains elusive. Overall survival remains at 50% to 55% even when heart transplantation is employed to treat patients with irreversible myocardial injury. The requirement for heparin for anticoagulation and an external blood flow circuit contribute to the high incidence of sepsis and severe bleeding limiting the length of time that children can be supported on ECMO. However, for subsets of patients with heart failure, ECMO support for short time periods (less than 10 days) remains an effective means of cardiac support.

Footnotes

Presented at the Third International Conference on Circulatory Support Devices for Severe Cardiac Failure, Pittsburgh, PA, Oct 28-30, 1994.

Address reprint requests to Dr del Nido, Department of Cardiac Surgery, Harvard Medical School, Children's Hospital, 300 Longwood Ave, Boston, MA 02115.

References

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pedro J. del Nido Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by del Nido, P. J. Search for Related Content PubMed PubMed Citation Articles by del Nido, P. J.