Ann Thorac Surg 2003;76:1441-1442
© 2003 The Society of Thoracic Surgeons
Original article: cardiovascular
Invited commentary
Brian W. Duncan, MDa
a Pediatric and Congenital Heart Surgery/M41, The Children's Hospital at The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
e-mail: duncanb{at}ccf.org
Kolovos and colleagues report recent results using postcardiotomy ECMO for children and compare them to their earlier experience reported by Kulik in 1996 [1]. Survival to hospital discharge improved from 33% in the previous study to 50% in this report, indicative of the evolution of this modality at a single center. ECMO was used earlier and more often in the present study (2.2% incidence of ECMO for all operative cases currently; 1.0% in the previous study). The diagnostic groups also reflect an evolution; survival for patients with successful two ventricle repairs improved (42% in the original study; 58% in the present study). However, changes in the distribution and survival in single ventricle patients had at least as large an impact on the improved overall results. Single ventricle patients with a systemic to pulmonary artery shunt increased from 11% to 28% of the total, while survival in this group improved from 25% in Kulik's report to 38% presently. This pattern has been reported elsewhere and reflects greater success with the use of ECMO for support of single ventricle patients after complex neonatal palliation as well as improved overall management in this group [2].
Although survival remained low for patients with a single ventricle and a cavopulmonary connection (17% previous study; 20% present study) the number of patients in this category fell substantially from 25% of the total in the previous study to only 7% in the present study. Improvements over time in management and patient selection have resulted in patients presenting as better candidates for the Fontan procedure with a decrease in the need for ECMO support. The increasing use of ECMO as a bridge to transplantation also contributed significantly to improved results. Kulik reported ECMO was used as a bridge to transplantation in two patients with only one survivor while 11% of the present total were successfully bridged to transplantation with three-quarters of these patients surviving.
Interestingly, the need for hemofiltration during support was associated with a poor outcome while abnormal renal function was not. Was the need for hemofiltration a surrogate for increased duration of support (also associated with poor outcomes) since patients on prolonged support are probably more likely to require hemofiltration? Regarding the use of rapid resuscitation ECMO, the mortality for these patients was high in this report (80%) and the authors state that ongoing cardiopulmonary resuscitation is a strong relative contraindication for ECMO. Many centers maintain that the salvage of children who arrest after cardiac surgery is one of the most important uses for ECMO with survival possible in the majority of these patients [3].
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References
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- Kulik T.J., Moler F.W., Palmisano J.M., et al. Outcome-associated factors in pediatric patients treated with extracorporeal membrane oxygenator after cardiac surgery. Circulation 1996;94(Suppl II):II63-II68.
- Pizarro C., Davis D.A., Healy R.M., Kerins P.J., Norwood W.I. Is there a role for extracorporeal life support after stage I Norwood?. Euro J Cardiothorac Surg 2001;19:294-301.[Abstract/Free Full Text]
- Jacobs J.P., Ojito J.W., McConaghey T.W., et al. Rapid cardiopulmonary support for children with complex congenital heart disease. Ann Thorac Surg 2000;70:742-750.[Abstract/Free Full Text]
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