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Original Articles: Pediatric Cardiac

Survival of Children Requiring Repeat Extracorporeal Membrane Oxygenation After Congenital Heart Surgery

^a Department of Cardiac Surgery, Children's Hospital Boston, Boston, Massachusetts
^b Department of Cardiology, Children's Hospital Boston, Boston, Massachusetts

Accepted for publication January 26, 2011.

^_* Address correspondence to Dr Shuhaiber, Cincinnati Children's Hospital, 3333 Burnett Ave, MLC 2004, Cincinnati, OH 45229 (Email: jeffrey.shuhaiber{at}gmail.com).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
Background: Clinical indications and outcomes for children requiring multiple extracorporeal membrane oxygenation (ECMO) runs during a single hospital admission are rarely reported. We review indications, cannulation techniques, and outcomes for infants requiring multiple ECMO runs after congenital heart surgery.

Methods: Demographic and ECMO-related data for all children requiring multiple ECMO runs during a single hospital admission from1995 to 2008 were extracted from our institution's ECMO database. Survival was defined as survival to hospital discharge. Demographic and ECMO data were compared between survivors and nonsurvivors using the Mann-Whitney test for continuous and Fisher's exact test for categorical data.

Results: Twenty children (5% of 391 ECMO runs) with a median age of 5 days (range, 4 to 180 days) and weight of 3.22 kg required repeat ECMO support for persistent cardiopulmonary dysfunction despite successful weaning from an index ECMO run. Of the two-ventricle repair group, tetralogy of Fallot, truncus arteriosus, and transposition constituted the majority of cardiac diagnoses (75%), whereas single-ventricle physiology made up the rest (25%). The median total ECMO duration was 191 hours (range, 77 to 485 hours), and median hospital length of stay was 41 days (range, 6 to 297 days). Five (25%) patients survived to discharge. When survivors were compared with nonsurvivors, there were no significant differences in demographics, single or biventricular repair, indication for ECMO support, or need for surgical reoperation while on ECMO. However, the incidence of renal failure was higher in nonsurvivors than in survivors after multiple ECMO runs (12 versus 2.0; p = 0.03).

Conclusions: Survival in children undergoing congenital heart surgery requiring multiple ECMO runs is low, but 1 in 4 patients will survive to discharge. If a correctable lesion or ventricular impairment is present, repeat ECMO support may be justified. Development of renal failure is associated with nonsurvival in these patients.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
Extracorporeal membrane oxygenation (ECMO) has been shown to be useful in the management of children with refractory cardiorespiratory failure after congenital heart surgery and is commonly used for this indication [1–4]. Survival for children supported with ECMO after cardiac surgery is reported to be between 35% and 60% [5–8]. Patients who experience recurrent cardiorespiratory dysfunction after weaning off ECMO after congenital heart surgery may be considered for another period of ECMO support in some institutions. Repeat ECMO use for children after successful separation from the first ECMO use may be challenging because of technical difficulties with recannulation, as well as concerns about the long-term viability of the circulation. Outcomes for children who require repeat ECMO exposure have not been well reported to guide the use of repeat ECMO exposure in these children.

In this report we evaluate our experience with use of multiple ECMO runs for cardiorespiratory dysfunction during a single hospital admission after congenital heart surgery. The indications, complications, and outcomes for multiple ECMO runs in children after congenital heart surgery are evaluated.

	Material and Methods

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The Committee for Clinical Research at Children's Hospital Boston, Boston, approved the retrospective review of medical records for purposes of this study. We extracted all patients 18 years of age or younger with cardiac disease supported by more than one ECMO run after congenital cardiac surgery between January 1995 through December 2008 from our cardiac ECMO database. An ECMO run was defined as being complete when the patient was weaned off ECMO and decannulated from ECMO. Recannulation for the purposes of reinstituting ECMO support after the removal of ECMO cannulas after the first ECMO run regardless of the time elapsed between the first and second ECMO runs was defined as second ECMO exposure. Cardiopulmonary failure for purposes of this study was defined as cardiac or respiratory failure or both failing to respond to conventional medical therapies. Renal failure was defined as a serum creatinine of greater than 1.5 mg/dL (all ages) or use of renal replacement therapy (peritoneal dialysis or hemodialysis). In our institution, ECMO weaning is achieved by gradual reduction of ECMO flows to 20% of the flow required to support ECMO patients, followed by clamping. Patient hemodynamics, level of inotropic support needed to maintain cardiac function, echocardiographic assessment of cardiac function, lung function assessed by blood gases, laboratory data such as serum lactate levels, and urine are used to determine readiness for decannulation. The decision to remove ECMO support is made jointly by primary physician and surgeon caring for the patient with the expectation that the patient had sufficiently recovered and would not need further ECMO support.

Survival was defined as survival to hospital discharge to home, chronic-care facility, or another institution. Demographic details, indication for ECMO, ECMO support details, and complications during hospital admission were collected. Demographic, ECMO indications, ECMO course, and complications were compared for those who survived to hospital discharge and those who died. Continuous data were compared using the Mann-Whitney test, and categorical data were compared using the Fisher's exact test. A probability value of less than 0.05 was considered statistically significant. Statistical analysis was conducted using SPSS v17.0 (SPSS Inc, Chicago, IL), and data are summarized as medians with ranges, and as numbers and proportions.

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
Study Population
During the study period, 20 patients (5% of 391 ECMO runs) received two or more ECMO runs during the same hospital admission. During 1995 to 2008, 328 patients underwent single ECMO runs after congenital heart surgery, and 168 (51%) survived to hospital discharge. Table 1 shows selected demographic and diagnosis-related features of the study cohort. Eighteen patients had two runs of ECMO, 1 patient had three ECMO runs, and 1 patient had four ECMO runs. Mode of ECMO support in all patients and all episodes was venoarterial. Fifteen patients (75%) were neonates, and males made up 28% of the cohort (n = 9). Median age at first ECMO cannulation was 5 days (range, 4 to 180 days). The median duration was 5 days, with a range of 0 to 157 days. Patient details including indication for the first and second ECMO runs are shown in Table 2. Indications for the first ECMO run included postcardiotomy cardiac failure in 5, adjunct to postoperative cardiopulmonary resuscitation in 12, and failure to wean from cardiopulmonary bypass after cardiac surgery in 3. Indications for the second run included cardiac failure in 7, adjunct to cardiopulmonary resuscitation in 12, and failure to wean from cardiopulmonary bypass after cardiac surgery in 1. Eight (40%) patients had a hemodynamically significant residual lesion that required reintervention after initial corrective or palliative procedure.

Extracorporeal Membrane Oxygenation Cannulation Sites, Duration, and Complications
Sites for ECMO cannulation during the first ECMO run included thoracic sites (right atrium and aorta; n = 18, 90%) and neck vessels (right internal jugular vein and right common carotid artery; n= 2, 20%). Six patients (30%) were cannulated using a different venous and arterial site for the second and subsequent ECMO runs. Four patients who had ECMO with prior chest (right atrium and aorta) cannulation were changed to neck vessel cannulation (right internal jugular and right common carotid artery), and 2 with prior neck cannulation were changed to chest cannulation. Median cumulative ECMO duration was 191 hours (range, 77 to 485 hours). The median duration of the second ECMO run was 127 hours (range, 5 to 289 hours) and was longer than the first ECMO run of 86 hours (range, 6 to 295 hours). Complications were common, and one or more complications occurred in the majority of patients (n =18; 90%). Most common complications included cannulation site or surgical bleeding requiring administration of blood products or surgical reexploration (n = 14; 70%), and renal failure (n = 14, 70%). Bloodstream infections occurred in 10 patients (50%), and neurologic injury, including intracranial bleeding or infarction diagnosed by cranial ultrasound scan or computerized tomography, occurred in 3 patients (15%).

Cardiac Surgical Interventions for Study Patients
Fifteen patients (75%) required a cardiac surgical procedure after the first ECMO run to correct or palliate residual lesions after primary cardiac surgical procedures as shown in Table 2, and 5 patients (25%) required additional cardiac procedures after the second ECMO run. The details of the surgical procedure are described in Table 2. Among those who survived (n = 5) after repeat ECMO, 2 patients (40%) had significant hemodynamic residual lesions, whereas of those who did not survive (n = 15), 6 patients (40%) had significant hemodynamic lesions requiring reinterventions. Irreversible multiorgan failure was the cause of death or withdrawal of ECMO for futility in the majority of cases after the second ECMO run.

Differences Between Survivors and Nonsurvivors After Multiple Extracorporeal Membrane Oxygenation Runs
Differences in demographic variables and ECMO-related information between survivors and nonsurvivors are shown in Table 3. Survivors did not significantly differ from nonsurvivors with respect to age, sex, weight, prematurity, or the presence of single-ventricle circulation. Extracorporeal membrane oxygenation variables including cannulation strategy, indication for ECMO, and ECMO duration did not vary between survivors and nonsurvivors. There was a trend toward increased mortality in patients whose indication for ECMO remained the same as the first ECMO run compared with those patients in whom the indication for second ECMO run was new (92% versus 50%; p = 0.06). The incidence of renal failure in nonsurvivors was higher compared with survivors (80% versus 40%; p = 0.03) as shown in Table 3. There was no difference in surgical reintervention rate among the survivors and nonsurvivors.

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
Cardiogenic shock occurs in approximately 2% to 5% of all patients undergoing congenital cardiac surgery [4, 5]. Despite medical management with mechanical ventilation, ensuring adequate preload, enhancing myocardial contractility, and afterload reduction, some patients require ECMO support for management of refractory cardiorespiratory failure, often because there were associated significant residual lesions (40%) requiring surgical intervention. In the last 15 years use of ECMO to aid cardiopulmonary resuscitation of patients who undergo a cardiac arrest has gained widespread use when conventional resuscitative measures have failed to restore an effective circulation in these patients [9]. Despite improved survival with the use of ECMO in some patients with refractory cardiorespiratory failure after congenital heart surgery, some patients may sustain significant myocardial injury as a result of the cardiac surgery itself, through use of cardiopulmonary bypass, and during postoperative management. For these patients, the use of ECMO to support cardiopulmonary dysfunction may be invaluable, but they may fail to recover their myocardial function. Some patients may wean off the initial ECMO course but continue to have cardiorespiratory dysfunction and may become candidates for a second run of ECMO support. In this cohort of children with congenital heart disease requiring multiple ECMO runs for management of postoperative cardiorespiratory dysfunction, we show poor survival to hospital discharge. Survival after repeat ECMO is, however, inferior to that of patients requiring first-time ECMO for cardiac arrest after cardiac surgery [10]. Our group audited 110 Norwood patients, and reviewed each case for residual defects based on echocardiographic and catheterization data [11]. The technical scores were assigned and analyzed. Although most subprocedures were scored as optimal, distal arch reconstruction was most often inadequately repaired, and revisions of aortopulmonary shunts were the second commonest cause. Our institutional technical performance score correlated well with length of stay, ECMO, and hospital mortality.

In this study, of the 20 patients who required repeat ECMO during the same hospital admission, 8 had significant residual defects (Table 2) requiring direct surgical reoperation, whereas 15 patients required catheter or surgical reoperation to fix residual lesions or obtain optimal pulmonary blood flow regulation by revising the systemic to pulmonary shunts. However, despite correcting these residual lesions in two-ventricle repair or optimizing systemic to pulmonary blood flow ratios by shunt revision in single-ventricle palliation, there was no difference in survival to hospital discharge.

However, mortality was also significantly higher in patients who sustained renal failure during ECMO. Careful evaluation of other clinical management strategies, such as consideration for cardiac transplantation, should be discussed. Although ECMO as a bridge to heart transplantation outcome may not be favorable, it may be one of the few options together with mechanical ventricular support to change the outcome of heart failure patients [12].

Using multiinstitutional data from the Extracorporeal Life Support Organization's ECMO data registry, Fisher and colleagues [13] found no difference in survival for second ECMO runs when compared with those receiving one ECMO run. The majority of patients who received repeat ECMO runs were for primary cardiac indications (n = 74) and respiratory indications (n = 42). Although ECMO support for respiratory failure was the largest group for first-time ECMO run (48%), cardiac failure was the largest category in the repeat ECMO group (61%), which also included noncardiac surgical patients as well. Among those requiring ECMO support for cardiac failure, the study also found no difference in survival to discharge between the primary and repeat ECMO patients (44% versus 49%; p = 0.28). However, the multicenter Extracorporeal Life Support Organization study did not adjust for the urgency of ECMO, type of cardiac diagnoses, or history of prior cardiac surgery, nor did it adjust for children who were resuscitated more than once during the same hospital admission. Also the authors acknowledged that it was unclear how pediatric patients came to require second ECMO runs because rare events were lost in translation when analyzing an international patient registry. Also there was 30% missing data for both primary and second-time ECMO. Understanding that our sample size is small, contrary to the findings by Fisher and associates [13], we believe that patients with congenital heart disease who require more than one ECMO run during their hospitalization have poor survival outcomes.

With repeat ECMO comes the technical challenge of recannulation using prior ECMO cannulation or other vessels. If the chest is open, we prefer to access the aorta and right atrium directly. However, if the chest has been closed for a significant period, cannulation by means of the internal jugular vein and common carotid artery can be considered. We did not use the groin for cannulation in this cohort based on size of patient in this cohort. Formulating a cannulation strategy with the rest of the surgical team is important given that prior cannulation can result in future exclusion of that site. This is usually found when neck cannulation is performed in small babies, resulting in ligation of the jugular vein or occlusion of the carotid artery. We found no difference in outcomes (complication and survival) based on cannulation site access during repeat ECMO. However, the multicenter Extracorporeal Life Support Organization study detected fewer total complications using the same cannulation sites compared with those requiring new cannulation sites (3.7 versus 5.1; p =0.04) [13]. Less trauma and dissection by avoiding another cannulation site has its benefits, especially with reduced risk of hematoma and infection.

Our findings are in agreement with previous studies suggesting that renal insufficiency was an independent predictor for death [13, 14]. Fisher and coworkers [13, 14] found that renal insufficiency during the ECMO course was an independent risk factor for poor outcome among patients after repeat ECMO support. In addition, they found the total number of complications during the second ECMO course was another independent predictor for survival [15–17]. We recommend that repeat ECMO be instituted in selected patients whose cause of arrest is deemed reversible; however, this may not always be feasible before the arrest given the limited data and time available to allow for informed decision making. Although we witnessed a trend towards higher mortality for the same primary and repeat ECMO indication, further study is needed before we can exclude them altogether. Overall, patients who have irreversible end-organ injury and those whose second ECMO indication is unresolved cardiopulmonary dysfunction may not benefit from a second ECMO exposure; however, the decision to use a second ECMO run should be left to the discretion of the bedside care provider.

Our study has a few limitations. Although our study cohort may be the largest reported cohort of patients with multiple ECMO users, the cohort is too small to guide clinical decision making regarding choice of patients for repeat ECMO support. However, we can say that patients who require more than one ECMO run during the same hospitalization after congenital heart surgery have poor outcomes, with a survival rate of 25%. The diagnosis of central nervous system injury was based on radiologic evidence of central nervous system injury. Clinical evidence of neurologic injury and functional and neurologic outcome data were not collected for purposes of this study, and these may have underestimated the rate of neurologic injury. We also found that the occurrence of renal failure is associated with poorer outcomes.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

1. Suzuki Y, Yamauchi S, Daitoku K, Fukui K, Fukuda I. Extracorporeal membrane oxygenation circulatory support after congenital cardiac surgery ASAIO J 2009;55:53-57.[Medline]
2. Chan T, Thiagarajan RR, Frank D, Bratton SL. Survival after extracorporeal cardiopulmonary resuscitation in infants and children with heart disease J Thorac Cardiovasc Surg 2008;136:984-992.[Abstract/Free Full Text]
3. Lequier L, Joffe AR, Robertson CM, et al. Western Canadian Complex Pediatric Therapies Program Follow-up Group Two-year survival, mental, and motor outcomes after cardiac extracorporeal life support at less than five years of age J Thorac Cardiovasc Surg 2008;136976–83.e3.
4. Flick RP, Sprung J, Gleich SJ, et al. Intraoperative extracorporeal membrane oxygenation and survival of pediatric patients undergoing repair of congenital heart disease Paediatr Anaesth 2008;18:757-766.[Medline]
5. Hannan RL, Ojito JW, Ybarra MA, O'Brien MC, Rossi AF, Burke RP. Rapid cardiopulmonary support in children with heart disease: a nine-year experience Ann Thorac Surg 2006;82:1637-1641.[Abstract/Free Full Text]
6. Ravishankar C, Dominguez TE, Kreutzer J, et al. Extracorporeal membrane oxygenation after stage I reconstruction for hypoplastic left heart syndrome Pediatr Crit Care Med 2006;7:319-323.[Medline]
7. Kolovos NS, Bratton SL, Moler FW, et al. Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery Ann Thorac Surg 2003;76:1435-1442.[Abstract/Free Full Text]
8. Thourani VH, Kirshbom PM, Kanter KR, et al. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) in pediatric cardiac support Ann Thorac Surg 2006;82:138-145.[Abstract/Free Full Text]
9. Duncan BW, Ibrahim AE, Hraska V, et al. Use of rapid-deployment extracorporeal membrane oxygenation for the resuscitation of pediatric patients with heart disease after cardiac arrest J Thorac Cardiovasc Surg 1998;116:305-311.[Abstract/Free Full Text]
10. del Nido PJ, Dalton HJ, Thompson AE, Siewers RD. Extracorporeal membrane oxygenator rescue in children during cardiac arrest after cardiac surgery Circulation 1992;86(5 Suppl):II-300-II-304.
11. Bacha EA, Larrazabal LA, Pigula FA, et al. Measurement of technical performance in surgery for congenital heart disease: the stage I Norwood procedure J Thorac Cardiovasc Surg 2008;136:993-997997.e1–2.[Abstract/Free Full Text]
12. Kirklin JK. Mechanical circulatory support as a bridge to pediatric cardiac transplantation Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2008:80-85.
13. Fisher JC, Stolar CJ, Cowles RA. Evaluating cannulation strategies used during second courses of extracorporeal membrane oxygenation in a large cohort of pediatric patients J Pediatr Surg 2009;44:94-99.[Medline]
14. Fisher JC, Stolar CJ, Cowles RA. Extracorporeal membrane oxygenation for cardiopulmonary failure in pediatric patients: is a second course justified? J Surg Res 2008;148:100-108.[Medline]
15. Shann KG, Giacomuzzi CR, Harness L, et al. Complications relating to perfusion and extracorporeal circulation associated with the treatment of patients with congenital cardiac disease: consensus definitions from the Multi-Societal Database Committee for Pediatric and Congenital Heart Disease Cardiol Young 2008;18(Suppl 2):206-214.[Medline]
16. Thiagarajan RR, Laussen PC, Rycus PT, Bartlett RH, Bratton SL. Extracorporeal membrane oxygenation to aid cardiopulmonary resuscitation in infants and children Circulation 2007;116:1693-1700.[Abstract/Free Full Text]
17. Searles B, Gunst G, Terry B, Melchior R, Darling E. 2004 survey of ECMO in the neonate after open heart surgery: circuitry and team roles J Extra Corpor Technol 2005;37:351-354.[Medline]

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This Article Abstract Full Text (PDF) 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): Jeffrey Shuhaiber Peter C. Laussen Francis Fynn-Thompson Pedro del Nido Frank Pigula Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shuhaiber, J. Articles by Pigula, F. Search for Related Content PubMed PubMed Citation Articles by Shuhaiber, J. Articles by Pigula, F. Related Collections Extracorporeal circulation