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Ann Thorac Surg 2001;72:2095-2102
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Extracorporeal membrane oxygenation in children after repair of congenital cardiac lesions

^a Department of Cardiac and Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
^b Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
^c Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
^d ECMO Department, Vanderbilt University Medical Center, Nashville, Tennessee, USA
^e Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
^f Division of Cardiothoracic Anesthesia, Vanderbilt University Medical Center, Nashville, Tennessee, USA
^g Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA

* Address reprint requests to Dr Drinkwater, Cardiac and Thoracic Surgery, Vanderbilt University Medical Center, 1301 22nd Ave South, 2986 The Vanderbilt Clinic, Nashville, TN 37232-5734, USA
e-mail: aharona{at}slu.edu

Presented at the Forty-seventh Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 9–11, 2000.

	Abstract

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Background. The purpose of this study was to review our experience in the early application of extracorporeal membrane oxygenation (ECMO) in patients requiring mechanical assistance after cardiac surgical procedures.

Methods. The hospital records of all children requiring ECMO after cardiac operation were retrospectively reviewed, and an analysis of variables affecting survival was performed.

Results. Fifty pediatric patients between May 1997 and October 2000 required ECMO for cardiopulmonary support after cardiac operation. Patients ranged in age from 1 day to 11 years (median age, 40 days). Forty-eight patients underwent repair of congenital cardiac lesions and 2 were included after receiving a heart transplant. Twenty-two children could not be weaned from cardiopulmonary bypass and were placed on ECMO in the operating room for circulatory support. Of the 28 children who required ECMO in the intensive care unit, 10 had ECMO instituted after cardiopulmonary arrest (mean cardiopulmonary resuscitation time, 42 minutes; range, 5 to 110 minutes). In infants with single-ventricle physiology, survival to discharge was 61% (11 of 18 patients) as compared with 43% (14 of 32 patients) in those with biventricular physiology. Thirty of the 50 patients (60%) were successfully weaned from ECMO, of which 25 (83%) were discharged home. Overall survival to discharge in the entire cohort was 50%. Extracorporeal membrane oxygenation support greater than 72 hours was a grave prognostic indicator. Overall survival in this group was 36% (9 of 25 patients) compared with 56% (14 of 25 patients) in those with ECMO support less than 72 hours (p < 0.05). Univariate analysis revealed the presence of renal failure, extended periods of circulatory support, and a prolonged period of cardiopulmonary resuscitation as risk factors for mortality. The presence of shunt-dependent flow, operative procedure, and institution of ECMO in the intensive care unit did not alter survival.

Conclusions. Extracorporeal membrane oxygenation provides effective support for postoperative cardiac and pulmonary failure refractory to medical management. Early institution of ECMO may decrease the incidence of cardiac arrest and end-organ damage, thus increasing survival in these critically ill patients.

	Introduction

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Recent literature has documented survival rates of 40% to 50% in children requiring extracorporeal membrane oxygenation (ECMO) after repair of congenital heart lesions [1–8]. Rapid deployment ECMO for resuscitation of children with heart disease after cardiac arrest has yielded early survival rates of greater than 60% [9–11]. Impressive survival also has been noted in children requiring mechanical support as a bridge to cardiac transplantation [12–16]. Unfortunately, the results of patients with complex single-ventricle physiology requiring mechanical support are poor. The Extracorporeal Membrane Life Support Organization reports a 27% survival in patients with hypoplastic left heart syndrome (HLHS) undergoing stage I Norwood repair who required mechanical support [17]. Early, definitive repair of complex lesions, the deleterious effect of prolonged cardiopulmonary bypass on the immature myocardium, and neonatal pulmonary hypertensive disease are contributing factors to high early mortality. In this review, we report our results of ECMO after repair of congenital heart defects. Our purpose is to determine predictors of successful salvage of children requiring postcardiotomy mechanical assistance.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Data were obtained in a retrospective fashion from 50 consecutive pediatric patients who required postcardiotomy mechanical support from May 1997 to October 2000. Hospital records, operative reports, perfusion and pediatric intensive care unit (PICU) data, and outpatient clinic and telephone evaluations were used to obtain demographic information, operative and postoperative data, and patient follow-up information. Duration of follow-up ranged from 4 months to 3 years. The patients requiring ECMO represented 4%, of a total of 1,160 children undergoing cardiopulmonary bypass for correction of congenital heart defects. The demographic makeup of patients in this retrospective review is described in Table 1. Forty-eight patients underwent repair of congenital heart defects, and 2 required ECMO support after orthotopic heart transplantation. Thirty-two patients had two-ventricle physiology, and 18 patients had single-ventricle physiology (Table 2). In patients with single-ventricle physiology, 16 had HLHS, and 2 had pulmonary atresia with hypoplastic right ventricle. Extracorporeal membrane oxygenation was initiated through the chest in all patients except 1 who underwent repair of pulmonary atresia with ventricular septal defect with multiple aortopulmonary collaterals and had respiratory failure on the ward and subsequent neck cannulation in the PICU. Four patients were converted to carotid or jugular neck ECMO, and 2 patients each required two additional support runs of ECMO after initial weaning.

The ECMO circuit consists of a venous cannula draining to a compliant 30-mL silicon bladder (Medtronic Inc, Minneapolis, MN). Blood is drawn from the silicon bladder by the roller pump (Stockert Instruments/Sorin Biomedical, Irvine, CA) and fed into a 0.8-m² carbon dioxide–primed membrane oxygenator (Avecor-Medtronic Systems, Minneapolis, MN). For children weighing more than 11 kg, a second oxygenator is inserted once the child is placed on mechanical support or the child is quickly switched to a size-specific circuit. Blood then proceeds to an ECMOtherm II (Avecor-Medtronic Inc) heat exchanger and finally to the arterial inflow cannula (Fig 1).

View larger version (27K): [in this window] [in a new window]   Fig 1. Schematic diagram of the basic Vanderbilt University Medical Center extracorporeal membrane oxygenator circuit.

View larger version (39K): [in this window] [in a new window]   Fig 2. Completed lateral tunnel Fontan with cannulation of the Glenn shunt and right atrium for extracorporeal membrane oxygenation support.

View larger version (32K): [in this window] [in a new window]   Fig 3. Completed stage I Norwood with snared aortic and right atrial pursestring sutures in place.

Separation from mechanical assist was accomplished by maximizing inotropic and ventilator support and gradually decreasing ECMO flow rates in a fashion similar to weaning from cardiopulmonary bypass. When flow rates were decreased to approximately 25% of maximal support, the bridge between the arterial and venous systems was unclamped and the circuit allowed to recirculate. Transesophageal echocardiography was frequently used to assess myocardial function during the weaning process. The cannulas were subsequently removed after approximately 45 minutes to 1 hour of hemodynamic stability. All pursestring sutures were left in place and resnared. The chest was stented open after cannula removal.

Statistical analysis
Univariate and multivariate analysis including multiple linear regression and analysis of variance was performed using the following variables: age, sex, weight, anatomic diagnosis, shunt-dependent physiology, time to surgical intervention, preoperative inotropic support, presence of significant acidosis, ventilator dependence, prenatal diagnosis, cardiopulmonary bypass time, cross-clamp time, hypothermic circulatory arrest time, inability to wean from cardiopulmonary bypass in the operating room, cardiac arrest in the PICU, CPR time, the presence of renal failure on ECMO, and duration of ECMO. For categorical variables, directional tests were computed using the exact test and one-sided p values are reported. An overall survival curve of the sample was generated using the Cox regression survival analysis censoring on death and end of follow-up. All computations were performed using SPSS (SPSS Inc, Chicago, IL) for statistical analysis.

	Results

Top Abstract Introduction Material and methods Results Comment Discussion References

 
Between May of 1997 and October of 2000, 50 patients at the Vanderbilt University Medical Center required ECMO for cardiopulmonary support after cardiac operation. Patients ranged in age from 1 day to 11 years, with a median age of 40 days. Mean weight was 6.2 kg, with a range of 1.6 to 47.9 kg. Indications for ECMO were as follows: inability to wean from cardiopulmonary bypass (n = 22; 44%), cardiac arrest in the PICU (n = 10; 20%), low cardiac output requiring high-dose inotropic support (n = 11; 22%), and pulmonary vascular instability (n = 7; 14%). Demographic data are presented in Table 1. Thirty of the 50 patients (60%) were successfully weaned from ECMO. Of the 30 patients weaned from ECMO, 25 (83%) were discharged home. Overall survival to discharge was 50% in the entire cohort. Actuarial 1-year survival was 45%.

The children requiring mechanical support represented a wide spectrum of cardiac lesions. Sixteen patients had HLHS, 5 had pulmonary atresia with ventricular septal defect, 4 had dextro-transposition of the great arteries (D-TGA), 4 had truncus arteriosus, 4 had aortic stenosis, 3 had tetralogy of Fallot, 2 had coarctation of the aorta, 2 had dilated cardiomyopathy, 2 had double-outlet right ventricle, 1 had Ebstein’s anomaly, 1 had anomalous left coronary artery, 1 had recurrent left-ventricular outflow tract obstruction, and 5 had other diagnoses. Table 2 expresses survival as a function of anatomic diagnosis. Of the 16 patients with HLHS, 14 underwent stage I Norwood repair, 1 had stage II repair with Glenn shunt, and 1 had completion extracardiac Fontan procedure. Table 3 expresses survival as a function of operation. In patients after stage I Norwood repair, 10 (71%) were successfully weaned from ECMO and 9 (64%) survived to hospital discharge. One patient who underwent stage II Norwood repair and successful weaning from ECMO died in the cardiac catheterization laboratory after attempted balloon dilation and stenting of a stenotic left pulmonary artery.

There were 18 infants with single-ventricle aortopulmonary shunt-dependent pulmonary circulation and 32 with biventricular physiology. In infants with single-ventricle physiology, 14 underwent stage I Norwood procedure and 4 had tricuspid or pulmonic atresia. Patients with single-ventricle physiology who required ECMO support had improved survival when compared with those with biventricular physiology. In infants with single-ventricle physiology, survival to hospital discharge was 61% (11 of 18 patients) as compared with only 43% (14 of 32 patients) in those with biventricular physiology. Patients with biventricular physiology were generally older in age, tended to have poor preoperative cardiac function, and required more-complex intracardiac repair with longer cross-clamp times (mean, 52 versus 112 minutes) and cardiopulmonary bypass times (mean, 116 versus 146 minutes) when compared with those with single ventricles. Patients with biventricular physiology also required longer periods of ECMO support (mean, 88 versus 102 hours) and had a higher incidence of renal failure. The presence of shunt-dependent flow was not a risk factor for mortality. Mortality in both groups was almost exclusively owing to poor myocardial function. Neither the anatomic diagnosis nor the operative procedure was a statistically significant predictor of early survival. Only the presence of renal failure requiring hemodialysis during mechanical support was predictive of early mortality (p < 0.05).

Twenty-two patients required ECMO in the operating room for inability to wean from cardiopulmonary bypass. Of these, there were 12 early deaths (55%) and 1 late death (5%). The majority of patients had persistent cardiac failure and could not be successfully weaned from ECMO in the PICU. Eleven patients were placed on ECMO in the PICU for low cardiac output. Of these, 2 were weaned from ECMO and discharged home. Seven patients required mechanical support secondary to pulmonary hypertensive crises, of which 3 were successfully weaned from ECMO and discharged home (43%). There was no statistical difference with respect to survival in patients who were placed on ECMO in the PICU versus in the operating room. Extended periods of circulatory support adversely affected survival. Nine of 25 patients (36%) who required ECMO support greater than 72 hours survived to discharge compared with a survival of 56% (14 of 25) in patients who could be weaned from support in less than 72 hours. Ten patients required ECMO for cardiopulmonary arrest in the PICU with CPR times ranging from 5 to 110 minutes (mean, 45 minutes). In this group the early mortality was 20%, and 8 patients were discharged home. Patients with prolonged CPR times (> 45 minutes) tended to have poor survival.

Complications are listed in Table 4. The 4 children with renal failure defined as requiring hemodialysis while on ECMO could not be weaned from mechanical support. Three survivors and 3 nonsurvivors had culture-positive pneumonia. Four survivors and 3 nonsurvivors had sepsis. All patients undergoing transthoracic ECMO required at least one operative exploration for bleeding in the PICU. All patients who survived to discharge showed no evidence of focal neurologic deficits on physical examination.

	Comment

Top Abstract Introduction Material and methods Results Comment Discussion References

 
A number of recent reports on the use of ECMO for postcardiotomy myocardial or pulmonary failure and precardiotomy bridge to transplantation have shown encouraging results [7]. Survival rates of greater than 50% have been reported in children requiring mechanical support with either ECMO or ventricular assist device. The application of rapid deployment ECMO for acute cardiac or pulmonary arrest has become the standard of care in institutions that perform a large number of complex congenital cardiac procedures. Survival greater than 60% [9–11] may be achieved in this previously unsalvageable patient population when ECMO is instituted shortly after cardiopulmonary arrest [10]. Improved survival in children requiring mechanical support for inability to separate from cardiopulmonary bypass has also recently been reported [5]. Mechanical support after repair of complex congenital heart defects can often reverse profound myocardial dysfunction and correct the severe metabolic consequences of prolonged low cardiac output. Timing of mechanical support will directly impact survival [9–12]. Support of the failing myocardium is initiated with inotropic agents. Progressive decline in clinical status despite pharmacologic doses of inotropic therapy signals the need for mechanical assistance.

Many reports have identified initiation of ECMO in the operating room as an independent predictor for early mortality. Del Nido and colleagues [2] noted an overall survival of 46% in children with severe cardiac failure placed on ECMO. In the subset of patients who required ECMO in the operating room the survival was significantly worse, with 33% of patients surviving to discharge [2]. In our series, initiation of ECMO in the operating room for inability to separate from cardiopulmonary bypass did not adversely affect survival. Survival to discharge was 47% in patients placed on ECMO in the operating room versus 50% in those requiring ECMO in the PICU. The recent Duke University experience similarly did not find initiation of ECMO in the operating room to adversely impact survival [5].

In our study cardiopulmonary arrest in the PICU adversely affected survival only when CPR times were prolonged. Ten patients required ECMO after cardiopulmonary arrest in the PICU, of which 8 were successfully discharged home.

Children with CPR times greater than 45 minutes (range, 5 to 110 minutes; mean, 45 minutes) tended to have poor survival. As a consequence, we have maintained a mobile ECMO circuit, managed by an integrated ECMO team consisting of surgeons, pediatric intensivists, and ECMO technicians. To expedite initiation of ECMO, all children with high-risk physiology who are brought to the PICU with open, stented chests have snared aortic and right atrial pursestring sutures in place. To help avoid sudden cardiac arrest in the PICU, we consider progressive hemodynamic instability or acidosis despite pharmacologic doses of inotropic support as indications for mechanical support. Additional indications for ECMO in the PICU included pulmonary hypertensive crises despite nitric oxide therapy and shunt failure.

Prolonged periods of cardiopulmonary bypass, immature substrate-depleted myocardium, and hypertensive pulmonary vascular disease all contribute to the reported high mortality of neonates with single-ventricle physiology requiring ECMO support. The lowest postcardiotomy survival in the Extracorporeal Membrane Life Support Organization data registry (27%) is found in children with HLHS undergoing stage I Norwood repair. In our series, 10 of 14 patients with HLHS (71%) were successfully weaned from mechanical support, and 9 (64%) survived to hospital discharge. In those requiring ECMO in the operating room, all were successfully weaned from ECMO and discharged home. The presence of systemic to pulmonary shunts has been reported to be a relative contraindication to ECMO [2]. In our experience, systemic to pulmonary shunt-dependent physiology did not adversely affect outcome. Of the 18 patients with single-ventricle shunt-dependent physiology who required ECMO, survival to discharge was 55%. We and other have not found that the presence of an open shunt steals flow from the systemic circulation while on mechanical support [5]. Extracorporeal membrane oxygenation flow rates greater than 110 mL · kg^-1 · min^-1 with adequate alveolar ventilation (10 to 15 mL · kg^-1 · min^-1) and appropriate afterload reduction can achieve a balanced circulation without adverse effects on systemic perfusion. Flow rates can be adjusted on the basis of serial measure of arterial blood gases, lactic acid production, and mixed venous saturation to provide adequate systemic perfusion. We agree with Jaggers and associates [5] that maintaining adequate alveolar ventilation and perfusion may help prevent pulmonary edema and endothelial damage.

Patients with single-ventricle physiology who required ECMO had improved early survival (61% versus 43%) when compared with those with biventricular physiology. Patients with biventricular physiology tended to be older in age, have compromised preoperative cardiac function, and require more-complex intracardiac repair when compared with those with single ventricle physiology. Children with biventricular physiology also required longer periods of ECMO support and had a higher incidence of renal failure while receiving mechanical assistance. Postcardiotomy patients with single-ventricle physiology and depressed myocardial function or reactive pulmonary vasculature may represent a subgroup of patients with improved survival on ECMO. Transient myocardial dysfunction after cardiopulmonary bypass in the single-ventricle neonatal heart may derive significant benefit from a period of rest while receiving mechanical assistance. Furthermore, neonates with pulmonary vascular instability despite inhaled nitric oxide therapy may require only a limited period of mechanical assistance to avoid pulmonary vascular hypertensive crises and cardiopulmonary arrest in the immediate postoperative period. Patients with biventricular physiology who required ECMO most probably represent a subgroup of patients with compromised preoperative ventricular function who are at high risk for early death after repair of complex intracardiac lesions.

Several studies have shown that prolonged periods of mechanical support have a negative impact on survival [3, 16]. In our patient population 56% of patients requiring less than 72 hours of ECMO support were successfully discharged home compared with only 36% who required greater than 72 hours of support. Extended periods of ECMO also increased the incidence of renal failure and sepsis. In our more recent experience we have initiated weaning trials in appropriately selected patients within 24 to 48 hours of ECMO placement. We have found that several patients (n = 4) with borderline cardiac function while on ECMO were successfully weaned within a 36-hour period.

In summary, ECMO provides effective support for postoperative cardiac and pulmonary failure refractory to medical management. Renal failure, extended periods of circulatory support, and prolonged periods of CPR were all associated with high mortality. Shunt-dependent pulmonary circulation and institution of ECMO in the operating room did not adversely affect survival. Mechanical support should be initiated before development of significant metabolic abnormalities. In patients with hemodynamic instability in the PICU, a crystalloid-primed circuit available for rapid deployment and snared aortic and right atrial pursestring sutures allows for rapid initiation of ECMO.

	Discussion

Top Abstract Introduction Material and methods Results Comment Discussion References

 
DR W. STEVES RING (Dallas, TX): Could you comment a little bit about your management of the patients with shunt-dependent lesions, particularly the patients with hypoplastic hearts after the Norwood operation and how you manage your extracorporeal membrane oxygenation in terms of management of the shunt, management of their pulmonary status, and any additional tricks you have in managing that particular subgroup of patients?

DR AHARON: Doctor Ring, thank you for the excellent question. This issue of leaving the shunt open in infants with single-ventricular physiology requiring extracorporeal membrane oxygenation (ECMO) support has been much debated. Recently, Dr Ungerleider’s group at Duke University reported on the benefit of leaving the systemic to pulmonary shunt open in children requiring ECMO.

Although we do not have a matched cohort for comparison, we believe that leaving the shunt open and ventilating the infants at tidal volumes of approximately 10 to 15 mL · kg^-1 · min^-1, may decrease the incidence severity of endothelial damage and pulmonary edema and thus facilitate weaning from ECMO support. We believe, as does the Duke group, that keeping the lungs ventilated and perfused with an open pulmonary to systemic shunt may allow for more effective weaning from ECMO.

DR R. MARK STIEGEL (Charlotte, NC): One, were all these children postoperative patients in whom you initiated extracorporeal membrane oxygenation or were there some who had pulmonary hypertensive crises and who may have come in for other reasons?

DR AHARON: All infants in the series were postoperative patients with single or biventricular type physiology. The 2 patients who required extracorporeal membrane oxygenation after (ECMO) heart transplantation were both successfully discharged home.

DR STIEGEL: Did you look at the length of time between the decision to be placed on ECMO and the institution of ECMO as a risk factor?

DR AHARON: The length of time between the decision to place a child on ECMO and the institution of ECMO was examined using univariate and multivariate logistic regression analysis. We did not have the statistical power in 50 patients to effectively analyze time to placement on ECMO as a risk factor. From our early experience, we have lowered our threshold to institute ECMO, provided that medical management is maximized, both in the intensive care unit and in the operating room. In our more recent experience both cardiopulmonary resuscitation times and the number of children experiencing cardiopulmonary arrest in the pediatric intensive care unit has decreased. We do realize that although ECMO has its price in terms of bleeding, infection and so forth, it is better to err on the side of instituting ECMO earlier in the pediatric intensive care unit course rather than waiting for a second pulmonary hypertensive episode and then being forced to place the child on ECMO while performing chest compressions.

DR STIEGEL: In how many of your children did you use both left atrial or left ventricular drainage and right atrial drainage?

DR AHARON: The majority did not have both right and left atrial drainage. We were able to maintain good flows with appropriately sized cannulas using right atrial drainage. However, in those patients who had Fontan physiology, there were several in whom we could not obtain adequate ECMO flow rates despite appropriately sized arterial and venous cannulas. As a consequence, these patients required cannulation of the Glenn shunt and extracardiac conduit to obtain optimal ECMO flow.

DR STIEGEL: One of the things I have always been impressed with, though, in the children in whom we institute ECMO, both for neonatal distress as well as postoperatively, on echocardiography, if the aortic valve is not operating and closing, the left ventricle becomes extremely distended and the length of time, from the institution of ECMO and left ventricular recovery seems to be quite prolonged. Once I started draining the left ventricle, placing a left atrial catheter, and connecting it with a Y-type connection into the circuit, the left ventricle seemed to decompress a lot better and the recovery time shortened significantly.

DR AHARON: Doctor Stiegel you make an excellent point. Children with ventricular distension measured by transesophageal echocardiography, elevated central venous pressures, or examination of the heart in the open chest are appropriately decompressed with left atrial cannulation.

DR CHARLES B. HUDDLESTON (St. Louis, MO): I think you put up that you had 14 patients after stage I Norwood operation who received extracorporeal membrane oxygenation.

DR AHARON: Yes.

DR HUDDLESTON: What percentage of all your stage I Norwood patients does that represent over this time period?

DR AHARON: Of a total cohort in this period of aproximately 43 patients, 14 were placed on extracorporeal membrane oxygenation (ECMO).

DR HUDDLESTON: Approximately a third?

DR AHARON: About one third, yes.

DR HUDDLESTON: And of the 50 total patients that were put on ECMO over the 3-year period of time, what percentage of all your pump cases does that represent?

DR AHARON: Of those who were placed on ECMO?

DR HUDDLESTON: Yes. What I am getting at is the threshold for using ECMO I think varies from one place to another and is like left ventricular assist device; if you initiate left ventricular assist device support for whatever lesion relatively early on for reasons that others might not, the results with the treatment might be more effective.

DR AHARON: We are dealing with approximately 1,000 congenital heart repair cases. Our patient cohort represents 5% (50/1,000) of our total congenital repair cases.

DR HUDDLESTON: One thousand cases in 3 years at Vanderbilt?

DR AHARON: Something like that.

DR HUDDLESTON: Pump cases?

DR AHARON: Yes

DR HUDDLESTON: My last question is, how are you deciding about the trigger to initiate ECMO in patients who are in the intensive care unit with cardiopulmonary failure? This is, are you using a certain level of inotropic support and saying, this is it, we have got to go on ECMO, or is it a less objective, sort of a Gestalt kind of feeling about when to do it?

DR AHARON: Although establishment of rigid criteria for initiation of ECMO would be difficult in such a diverse patient population, we have developed relative indications for ECMO support. Progressive increase in inotropic support, acidosis, poor mixed venous gases, declining cardiac function with optimal medical management, and pulmonary hypertensive crises despite inhaled nitric oxide all are indications for ECMO. The addition of high-dose epinephrine, for example, may represent a relative indication for ECMO support in that a subset of patients requiring high-dose inotropic support will either suffer cardiopulmonary arrest or struggle through the first postoperative day with compromised cardiac function resulting in poor end-organ perfusion.

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