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Willems A, Anders MM, Garcia AV, Vogel AM, Yates AR, Muszynski JA, Alexander PMA, Steffen K, Emani S, Gehred A, Lyman E, Raman L. Management of Extracorporeal Membrane Oxygenation Anticoagulation in the Perioperative Period: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e53-e65. [PMID: 38959360 PMCID: PMC11216378 DOI: 10.1097/pcc.0000000000003490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic review-informed, modified Delphi consensus regarding the management of children on extracorporeal membrane oxygenation (ECMO) undergoing invasive procedures or interventions developed by the Pediatric Anticoagulation on ECMO CollaborativE (PEACE) Consensus Conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION ECMO anticoagulation and hemostasis management in the perioperative period and during procedures. DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts. Seventeen references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. DATA SYNTHESIS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. Four good practice statements, 7 recommendations, and 18 consensus statements are presented. CONCLUSIONS Although agreement among experts was strong, important future research is required in this population for evidence-informed recommendations.
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Affiliation(s)
- Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marc M Anders
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Alejandro V Garcia
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Adam M Vogel
- Departments of Surgery and Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Andrew R Yates
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University of Medicine, Columbus, OH
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Katherine Steffen
- Department of Pediatrics (Pediatric Critical Care Medicine), Stanford University, Palo Alto, CA
| | - Sitaram Emani
- Department of Cardiovascular Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital, Columbus, OH
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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Mensink HA, Desai A, Cvetkovic M, Davidson M, Hoskote A, O'Callaghan M, Thiruchelvam T, Roeleveld PP. The approach to extracorporeal cardiopulmonary resuscitation (ECPR) in children. A narrative review by the paediatric ECPR working group of EuroELSO. Perfusion 2024; 39:81S-94S. [PMID: 38651582 DOI: 10.1177/02676591241236139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Extracorporeal Cardiopulmonary Resuscitation (ECPR) has potential benefits compared to conventional Cardiopulmonary Resuscitation (CCPR) in children. Although no randomised trials for paediatric ECPR have been conducted, there is extensive literature on survival, neurological outcome and risk factors for survival. Based on current literature and guidelines, we suggest recommendations for deployment of paediatric ECPR emphasising the requirement for protocols, training, and timely intervention to enhance patient outcomes. Factors related to outcomes of paediatric ECPR include initial underlying rhythm, CCPR duration, quality of CCPR, medications during CCPR, cannulation site, acidosis and renal dysfunction. Based on current evidence and experience, we provide an approach to patient selection, ECMO initiation and management in ECPR regarding blood and sweep flow settings, unloading of the left ventricle, diagnostics whilst on ECMO, temperature targets, neuromonitoring as well as suggested weaning and decannulation strategies.
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Affiliation(s)
- H A Mensink
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - A Desai
- Paediatric Intensive Care, Royal Brompton Hospital, London, UK
| | - M Cvetkovic
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M Davidson
- Critical Care Medicine, Royal Hospital for Children, Glasgow, UK
| | - A Hoskote
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - M O'Callaghan
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - T Thiruchelvam
- Paediatric Cardiac Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - P P Roeleveld
- Paediatric Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
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3
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Zhou J, Wang H, Zhao Y, Shao J, Jiang M, Yue S, Lin L, Wang L, Xu Q, Guo X, Li X, Liu Z, Chen Y, Zhang R. Short-Term Mortality Among Pediatric Patients With Heart Diseases Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2023; 12:e029571. [PMID: 38063152 PMCID: PMC10863771 DOI: 10.1161/jaha.123.029571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 11/08/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation serves as a crucial mechanical circulatory support for pediatric patients with severe heart diseases, but the mortality rate remains high. The objective of this study was to assess the short-term mortality in these patients. METHODS AND RESULTS We systematically searched PubMed, Embase, and Cochrane Library for observational studies that evaluated the short-term mortality of pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation. To estimate short-term mortality, we used random-effects meta-analysis. Furthermore, we conducted meta-regression and binomial regression analyses to investigate the risk factors associated with the outcome of interest. We systematically reviewed 28 eligible references encompassing a total of 1736 patients. The pooled analysis demonstrated a short-term mortality (defined as in-hospital or 30-day mortality) of 45.6% (95% CI, 38.7%-52.4%). We found a significant difference (P<0.001) in mortality rates between acute fulminant myocarditis and congenital heart disease, with acute fulminant myocarditis exhibiting a lower mortality rate. Our findings revealed a negative correlation between older age and weight and short-term mortality in patients undergoing veno-arterial extracorporeal membrane oxygenation. Male sex, bleeding, renal damage, and central cannulation were associated with an increased risk of short-term mortality. CONCLUSIONS The short-term mortality among pediatric patients undergoing veno-arterial extracorporeal membrane oxygenation for severe heart diseases was 45.6%. Patients with acute fulminant myocarditis exhibited more favorable survival rates compared with those with congenital heart disease. Several risk factors, including male sex, bleeding, renal damage, and central cannulation contributed to an increased risk of short-term mortality. Conversely, older age and greater weight appeared to be protective factors.
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Affiliation(s)
- Jingjing Zhou
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Haiming Wang
- Department of EndocrinologyChinese PLA Central Theater Command General HospitalWuhanChina
| | - Yunzhang Zhao
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Junjie Shao
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Min Jiang
- Department of Respiratory and Critical CareThe Eighth Medical Center of Chinese PLA General HospitalBeijingChina
| | - Shuai Yue
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Lejian Lin
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Lin Wang
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Qiang Xu
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Xinhong Guo
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Xin Li
- Department of Health ServicesThe First Medical Center of Chinese PLA General HospitalBeijingChina
| | - Zifan Liu
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Yundai Chen
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
| | - Ran Zhang
- Department of Cardiovascular MedicineChinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
- State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital & Chinese PLA Medical SchoolBeijingChina
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4
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Extracorporeal Membrane Oxygenation in Congenital Heart Disease. CHILDREN 2022; 9:children9030380. [PMID: 35327752 PMCID: PMC8947570 DOI: 10.3390/children9030380] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/04/2022] [Accepted: 03/07/2022] [Indexed: 11/24/2022]
Abstract
Mechanical circulatory support (MCS) is a key therapy in the management of patients with severe cardiac disease or respiratory failure. There are two major forms of MCS commonly employed in the pediatric population—extracorporeal membrane oxygenation (ECMO) and ventricular assist device (VAD). These modalities have overlapping but distinct roles in the management of pediatric patients with severe cardiopulmonary compromise. The use of ECMO to provide circulatory support arose from the development of the first membrane oxygenator by George Clowes in 1957, and subsequent incorporation into pediatric cardiopulmonary bypass (CPB) by Dorson and colleagues. The first successful application of ECMO in children with congenital heart disease undergoing cardiac surgery was reported by Baffes et al. in 1970. For the ensuing nearly two decades, ECMO was performed sparingly and only in specialized centers with varying degrees of success. The formation of the Extracorporeal Life Support Organization (ELSO) in 1989 allowed for the collation of ECMO-related data across multiple centers for the first time. This facilitated development of consensus guidelines for the use of ECMO in various populations. Coupled with improving ECMO technology, these advances resulted in significant improvements in ECMO utilization, morbidity, and mortality. This article will review the use of ECMO in children with congenital heart disease.
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Abdelmohsen G, Al-Ata J, Alkhushi N, Bahaidarah S, Baho H, Abdelsalam M, Bekheet S, Ba-Atiyah W, Alghamdi A, Fawzy A, Elakaby A, Al-Radi O, Jamjoom A, Elassal A, Shihata M, Azhar A, Zaher Z, Maghrabi K, Mashali M, Dohain A. Cardiac Catheterization During Extracorporeal Membrane Oxygenation After Congenital Cardiac Surgery: A Multi-Center Retrospective Study. Pediatr Cardiol 2022; 43:92-103. [PMID: 34328521 DOI: 10.1007/s00246-021-02696-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/23/2021] [Indexed: 11/26/2022]
Abstract
Cardiac catheterization can affect clinical outcomes in patients on extracorporeal membrane oxygenation (ECMO) after congenital heart surgery; however, its effect in this group of patients remains unclear. This study aimed to evaluate the safety and outcome of cardiac catheterization in patients undergoing ECMO after congenital cardiac surgery and determine predictors that influence successful weaning. This retrospective cohort study included pediatric patients who underwent cardiac catheterization while on ECMO after congenital heart surgery in two cardiac centers between November 2012 and February 2020. Predictors of successful weaning from ECMO were studied using univariate and multivariate logistic regression analyses. Of 123 patients on ECMO support after congenital cardiac surgery, 60 patients underwent 60 cardiac catheterizations (31 diagnostic and 29 interventional). Thirty-four (56.7%) and 22 patients (36.7%) underwent successful decannulation from ECMO support and survived after hospital discharge, respectively. Patients who underwent earlier catheterization (within 24 h of ECMO initiation) had more successful weaning from ECMO and survival compared to others. Patients who underwent an interventional procedure (interventional catheterization or redo cardiac surgery after cardiac catheterization) had better survival than those who underwent only diagnostic catheterization (P = 0.038). Shorter durations of ECMO was the most important predictor of successful weaning from ECMO. Early cardiac catheterization greatly impacts successful weaning from ECMO and survival. Patients with correctable lesions amenable either by catheterization or redo surgery are more likely to survive. Shorter durations of ECMO could have a significant influence on successful weaning from ECMO and survival.
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Affiliation(s)
- Gaser Abdelmohsen
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia.
- Paediatric Cardiology Division, Department of Paediatrics, Kasr Al Ainy School of Medicine, Cairo University, 99 El-Manial St., Cairo, 11451, Egypt.
| | - Jameel Al-Ata
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Naif Alkhushi
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Saud Bahaidarah
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Haysam Baho
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Mohamed Abdelsalam
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Cardiology Department, Benha University, Benha, Egypt
| | - Samia Bekheet
- Paediatric Cardiology Division, Department of Paediatrics, Kasr Al Ainy School of Medicine, Cairo University, 99 El-Manial St., Cairo, 11451, Egypt
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Wejdan Ba-Atiyah
- Paediatric Cardiology Division, Department of Paediatrics, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Abdulhadi Alghamdi
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Ahmed Fawzy
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Ahmed Elakaby
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Department, Al -Azhar University, Cairo, Egypt
| | - Osman Al-Radi
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Cardiac Surgery Division, Department of Surgery, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Ahmed Jamjoom
- Cardiac Surgery Division, Department of Surgery, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Ahmed Elassal
- Cardiac Surgery Division, Department of Surgery, King Abdulaziz University, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | - Mohammad Shihata
- Cardiac Surgery Division, Department of Surgery, King Faisal Specialist Hospital and Research Center, P.O. Box 40047, Jeddah, 21499, Saudi Arabia
| | - Ahmed Azhar
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Zaher Zaher
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Khadijah Maghrabi
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
| | - Mohamed Mashali
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Cardiology Division, Department of Paediatrics, Kasr Al Ainy School of Medicine, Cairo University, 99 El-Manial St., Cairo, 11451, Egypt
| | - Ahmed Dohain
- Paediatric Cardiology Division, Department of Paediatrics, King Abdulaziz University Hospital, P.O.BOX: 80215, Jeddah, 21589, Saudi Arabia
- Paediatric Cardiology Division, Department of Paediatrics, Kasr Al Ainy School of Medicine, Cairo University, 99 El-Manial St., Cairo, 11451, Egypt
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Roeleveld PP, Blom NA, Hazekamp MG. Invited Commentary: Residual Lesions and ECMO: Seek and You Shall Find Ways to Narrow the ECMO Gap. World J Pediatr Congenit Heart Surg 2021; 12:614-615. [PMID: 34597208 DOI: 10.1177/21501351211035785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Nicolaas A Blom
- 4501Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G Hazekamp
- 4501Leiden University Medical Center, Leiden, The Netherlands
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Soynov IA, Kornilov IA, Kulyabin YY, Zubritskiy AV, Ponomarev DN, Nichay NR, Murashov IS, Bogachev-Prokophiev AV. Residual Lesion Diagnostics in Pediatric Postcardiotomy Extracorporeal Membrane Oxygenation and Its Outcomes. World J Pediatr Congenit Heart Surg 2021; 12:605-613. [PMID: 34597209 DOI: 10.1177/21501351211026594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To assess the impact of diagnostic procedures in identifying residual lesions during extracorporeal membrane oxygenation (ECMO) on survival after pediatric cardiac surgery. METHODS Between January 2012 and December 2017, 74 patients required postcardiotomy ECMO. Patients were retrospectively divided into 2 groups: Group I underwent only echocardiography ([echo only] 46 patients, 62.2%) and group II (echo+) underwent additional diagnostic tests (ie, computed tomography [CT] or cardiac catheterization; 28 patients, 37.8%). Propensity score matching was used to balance the 2 groups by baseline characteristics. RESULTS Two equal groups (28 patients in each group) were formed by propensity score matching. Fourteen (50%) patients in the echo-only group and 20 (71%) patients in the echo+ group were successfully weaned from ECMO (P = .17). Four (14.3%) patients survived in the echo-only group and 15 (53.5%) patients survived in the echo+ group (P = .004). Patients in the echo+ group had a lower chance of dying compared to the echo-only group (odds ratio, 0.14.6; 95% CI, 0.039-0.52; P = .003). The residual lesions, which may have served as a mortality factor, were found by autopsy in 8 (40%) patients in the echo-only group, while none were found in the echo+ group (P = .014). CONCLUSIONS The autopsies of patients who died despite postcardiotomy ECMO support showed that in 40% of cases that had been investigated by echo only, residual lesions that had not been detected by echocardiography were present. The cardiac catheterization and CT during ECMO are effective and safe for identifying residual lesions. Early detection and repair of residual lesions may increase the survival rate of pediatric cardiac patients on ECMO.
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Affiliation(s)
- Ilya A Soynov
- Department of Congenital Heart Surgery, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Igor A Kornilov
- Department of Anesthesiology, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Yuriy Y Kulyabin
- Department of Congenital Heart Surgery, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Alexey V Zubritskiy
- Department of Congenital Heart Surgery, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Dmitry N Ponomarev
- Department of Anesthesiology, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Nataliya R Nichay
- Department of Congenital Heart Surgery, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
| | - Ivan S Murashov
- Department of Pathology, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation
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Bhaskar P, Davila S, Hoskote A, Thiagarajan R. Use of ECMO for Cardiogenic Shock in Pediatric Population. J Clin Med 2021; 10:jcm10081573. [PMID: 33917910 PMCID: PMC8068254 DOI: 10.3390/jcm10081573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/18/2021] [Accepted: 03/03/2021] [Indexed: 01/11/2023] Open
Abstract
In children with severe advanced heart failure where medical management has failed, mechanical circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) or ventricular assist device represents life-sustaining therapy. This review provides an overview of VA ECMO used for cardiovascular support including medical and surgical heart disease. Indications, contraindications, and outcomes of VA ECMO in the pediatric population are discussed.VA ECMO provides biventricular and respiratory support and can be deployed in rapid fashion to rescue patient with failing physiology. There have been advances in conduct and technologic aspects of VA ECMO, but survival outcomes have not improved. Stringent selection and optimal timing of deployment are critical to improve mortality and morbidity of the patients supported with VA ECMO.
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Affiliation(s)
- Priya Bhaskar
- Division of Pediatric Critical Care, UT Southwestern Medical Center, Children’s Medical Center, Dallas, TX 75235, USA; (P.B.); (S.D.)
| | - Samuel Davila
- Division of Pediatric Critical Care, UT Southwestern Medical Center, Children’s Medical Center, Dallas, TX 75235, USA; (P.B.); (S.D.)
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK;
| | - Ravi Thiagarajan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence:
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Cavallaro G, Di Nardo M, Hoskote A, Tibboel D. Editorial: Neonatal ECMO in 2019: Where Are We Now? Where Next? Front Pediatr 2021; 9:796670. [PMID: 35059363 PMCID: PMC8764394 DOI: 10.3389/fped.2021.796670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
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10
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Commentary: Time is muscle. J Thorac Cardiovasc Surg 2020; 159:1968-1969. [PMID: 31955932 DOI: 10.1016/j.jtcvs.2019.11.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 11/21/2022]
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Kang SL, Lee KJ, Stanisic A, Chaturvedi RR. Using the arterial cannula for cardiac catheterization in neonates and small infants supported by extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2020; 159:e79-e81. [PMID: 31126658 DOI: 10.1016/j.jtcvs.2019.03.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/19/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022]
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Accessing extracorporeal membrane oxygenation circuits to perform emergent interventional cardiac catheterisation. Cardiol Young 2019; 29:1290-1293. [PMID: 31511102 DOI: 10.1017/s1047951119001446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cardiac catheterisation in patients on extracorporeal membrane oxygenation (ECMO) may reveal new information leading to modification of a therapeutic plan and correction of newly recognised or residual lesions. Complications associated with cardiac catheterisation during ECMO are not uncommon and often related to the access site. We report a straightforward technique for accessing the ECMO circuit to perform an emergent cardiac catheterisation in two patients with hypoplastic left heart syndrome decompensated after Norwood I, due to presumed systemic-to-pulmonary artery shunt obstruction.
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13
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Cardiac catheterization procedures in pediatric patients undergoing extracorporeal membrane oxygenation cardiac catheterization, ECMO. Anatol J Cardiol 2019; 18:425-430. [PMID: 29256878 PMCID: PMC6282899 DOI: 10.14744/anatoljcardiol.2017.7927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: Extracorporeal membrane oxygenation (ECMO) is a lifesaving intervention for pediatric patients with respiratory and/or cardiovascular failure. In this study, we evaluated the cardiac catheterization results of pediatric patients on ECMO support. Methods: Between January 2012 and October 2016, 98 patients (5.2% of all surgery patients) needed ECMO support during perioperative cardiac surgery. We retrospectively reviewed the clinical data of 16 patients who underwent cardiac catheterization under ECMO support. Results: The median age at catheterization was 6.5 months (range, 3.3–60 months), and the median weight was 6.0 kg (range, 3.7–16 kg). Eight of the catheterizations were diagnostic, and the remaining eight were interventional. Five out of these eight patients underwent surgical palliation after diagnostic catheterization. Right pulmonary artery (RPA) stenting, right ventricular outflow tract (RVOT) stenting, combined left pulmonary artery (LPA) and RVOT stenting, combined LPA and modified Blalock-Taussig shunt stenting, bilateral pulmonary artery balloon angioplasty, and bilateral pulmonary artery stenting were each performed once, whereas LPA stenting was performed in two different patients. In one patient undergoing RVOT stenting, a complete atrioventricular block developed, resulting in hypotension; however, this was overcome with an ECMO flow increase. In another patient, the ECMO tubing disconnected from the arterial line. Minor vascular complications were seen in three patients. Twelve patients (75%) were successfully weaned from ECMO after the procedure and ten (63%) were discharged. Conclusion: Diagnostic and interventional cardiac catheterization can be safely and effectively performed in patients on ECMO. If the patient cannot be weaned from ECMO support, clinicians should consider performing an early angiogram either to treat or clarify the underlying problem.
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Yu X, Zhou RH. ECMO support in cardiac intervention of severe pulmonary stenosis: A case report. Medicine (Baltimore) 2019; 98:e15754. [PMID: 31096540 PMCID: PMC6531056 DOI: 10.1097/md.0000000000015754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
RATIONALE Patients of critical pulmonary artery stenosis would face severe hypoxemia, cardiac failure as well as massive hemorrhage during percutaneous balloon dilation and pulmonary arterial stent implantation. Here, we present a case in which the elective use of extracorporeal membrane oxygenation (ECMO) support successfully facilitated safe percutaneous balloon dilation of pulmonary artery and stent implantation on a patient with severe pulmonary artery stenosis caused by aorto-arteritis. PATIENT CONCERNS A 47-year-old man was hospitalized due to 10 years of post-exercise exhaustion and shortness of breath. Half a month ago the symptoms deteriorated. He also manifested systemic edema and could only sit upright to breath during night time. Computed tomographic angiography (CTA) indicated severe pulmonary stenosis caused by aorto-arteritis. DIAGNOSES Right pulmonary artery stenosis, left pulmonary artery occlusion, severe tricuspid regurgitation, right atrium, and ventricle enlargement, atrial fibrillation with rapid ventricular rates, NYHA class IV, pulmonary infection. INTERVENTIONS V-A ECMO support was considered during percutaneous balloon dilation of pulmonary artery and stent implantation. OUTCOMES The patient remained hemodynamically stable throughout the procedure with no inotropic support. ECMO was successfully weaned off after the intervention, with no procedural complications. Postoperative echocardiography indicated much better heart function, and he was discharged uneventfully 5 days later. CONCLUSION V-A ECMO is capable of preventing hypoxemia and providing effective circulation support during cardiac intervention in patients of severe pulmonary stenosis.
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Abstract
Worldwide, the use of Extracorporeal Membrane Oxygenation (ECMO) for cardiac failure has been steadily increasing in the neonatal population and has become a widely accepted modality. Especially in centers caring for children with (congenital) heart disease, ECMO is now an essential part of care available for those with severe heart failure as a bridge to recovery, long term mechanical support, or transplantation. Short-term outcomes depend very much on indication. Hospital survival is ~40% for all neonatal cardiac ECMO patients combined. ECMO is being used for pre- and/or post-operative stabilization in neonates with congenital heart disease and in neonates with medical heart disease such as myocarditis, cardiomyopathy or refractory arrhythmias. ECMO use during resuscitation (ECPR) or for sepsis is summarized elsewhere in this special edition of Frontiers in Pediatrics. In this review article, we will discuss the indications for neonatal cardiac ECMO, the difficult process of patients' selection and identifying the right timing to initiate ECMO, as well as outline pros and cons for peripheral vs. central cannulation. We will present predictors of mortality and, very importantly, predictors of survival: what can be done to improve the outcomes for your patients. Furthermore, an overview of current insights regarding supportive care in neonatal cardiac ECMO is given. Additionally, we will address issues specific to neonates with single ventricle physiology on ECMO, for example cannulation strategies and the influence of shunt type (Blalock-Taussig shunt vs. "right ventricle to pulmonary artery" shunt). We will not only focus on short term outcomes, such as hospital survival, but also on the importance of long-term neuro-developmental outcomes, and we will end this review with suggestions for future research.
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Affiliation(s)
| | - Malaika Mendonca
- Pediatric Intensive Care Unit, Children's Hospital, Inselspital, Bern University Hospital, Bern, Switzerland
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Kuraim GA, Garros D, Ryerson L, Moradi F, Dinu IA, Garcia Guerra G, Moddemann D, Bond GY, Robertson CMT, Joffe AR. Predictors and outcomes of early post-operative veno-arterial extracorporeal membrane oxygenation following infant cardiac surgery. J Intensive Care 2018; 6:56. [PMID: 30202528 PMCID: PMC6122608 DOI: 10.1186/s40560-018-0326-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 08/21/2018] [Indexed: 01/23/2023] Open
Abstract
Background We aimed to determine predictors of, and outcomes after, veno-arterial extracorporeal membrane oxygenation instituted within 48 h after cardiac surgery (early ECMO) in young infants. Methods Patients ≤ 6 weeks old having cardiac surgery from 2003 to 2012 were enrolled prospectively. Patients cannulated pre-operatively, intra-operatively, or ≥ 48 h post-operatively were excluded. Variables at p ≤ 0.1 on univariate regression were entered into multiple logistic regression to predict early ECMO. Early-ECMO cases were matched 1:2 for six demographic variables, and death by age 2 years old (determined using conditional logistic regression; presented as odds ratio (OR), 95% confidence interval (CI)) and General Adaptive Composite scores at age 2 years (determined using Wilcoxon rank sum) were compared; p ≤ 0.05 was considered statistically significant. Results Of 565 eligible patients over the 10-year period, 20 had early ECMO instituted at a mean (standard deviation) of 12.4 (11.4) h post-operatively, 10 of whom had extracorporeal cardiopulmonary resuscitation. Of early-ECMO patients, 8 (40%) were found to have residual anatomic defects requiring intervention with catheterization (n = 1) and/or surgery (n = 7). On multiple regression, the post-operative day 1 highest vasoactive-inotrope score (OR 1.02; 95%CI 1.06,1.08; p < 0.001), highest lactate (OR 1.2; 95%CI 1.06,1.35; p = 0.003), and lowest base deficit (OR 0.82; 95%CI 0.71,0.94; p = 0.004), CPB time (OR 1.01; 95%CI 1.00,1.02; p = 0.002), and single-ventricle anatomy (OR 5.35; 95%CI 1.66,17.31; p = 0.005) were associated with early ECMO. Outcomes at 2 years old compared between early-ECMO and matched patients were mortality 11/20 (55%) vs 11/40 (28%) (OR 3.22, 95%CI 0.98,10.63; p = 0.054) and General Adaptive Composite median 65 [interquartile range (IQR) 58, 81.5] in 9 survivors vs 93 [IQR 86.5, 102.5] in 29 survivors (p = 0.02). Conclusions The identified risk factors for, and outcomes after, having early ECMO may aid decision making in the acute period and confirm that neurodevelopmental follow-up for these children is necessary. The hypothesis that earlier institution of ECMO may improve long-term outcomes requires further study.
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Affiliation(s)
- Gabriela A Kuraim
- 1Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta, 4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Daniel Garros
- 1Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta, 4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Lindsay Ryerson
- 1Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta, 4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Fahimeh Moradi
- 2School of Public Health, University of Alberta, Edmonton, Canada
| | - Irina A Dinu
- 2School of Public Health, University of Alberta, Edmonton, Canada
| | - Gonzalo Garcia Guerra
- 1Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta, 4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
| | - Diane Moddemann
- 3Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Gwen Y Bond
- 4Glenrose Rehabilitation Hospital, Edmonton, Canada
| | - Charlene M T Robertson
- 4Glenrose Rehabilitation Hospital, Edmonton, Canada.,5Division of Developmental Pediatrics, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Ari R Joffe
- 1Division of Pediatric Critical Care, Department of Pediatrics, University of Alberta, 4-546 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, Alberta T6G 1C9 Canada
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ECMO in children post cardiac surgery-opportunity for redress. Anatol J Cardiol 2017; 18:431-432. [PMID: 29256879 PMCID: PMC6282893 DOI: 10.14744/anatoljcardiol.2017.26116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
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Vecchione T, Hall SR, Brady KM, Qureshi AM, Parekh DR, McKenzie ED, Easley RB. Two Cases of Postoperative Right Coronary Artery Intervention in Pediatric Patients Following Congenital Heart Surgery. J Cardiothorac Vasc Anesth 2017; 32:429-432. [PMID: 28927696 DOI: 10.1053/j.jvca.2017.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Tricia Vecchione
- Department of Pediatric Anesthesiology, Pain and Perioperative Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Stuart R Hall
- Department of Pediatric Anesthesiology, Pain and Perioperative Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ken M Brady
- Department of Pediatric Anesthesiology, Pain and Perioperative Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Athar M Qureshi
- Department of Pediatrics, Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Dhaval R Parekh
- Department of Pediatrics, Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - E Dean McKenzie
- Department of Surgery, Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - R Blaine Easley
- Department of Pediatric Anesthesiology, Pain and Perioperative Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
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Burke CR, Chan T, Rubio AE, McMullan DM. Early Cardiac Catheterization Leads to Shortened Pediatric Extracorporeal Membrane Oxygenation Run Duration. J Interv Cardiol 2017; 30:170-176. [PMID: 28271557 DOI: 10.1111/joic.12368] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Cardiac catheterization in patients receiving extracorporeal life support (ECLS) has previously been shown to be safe and, in many cases, therapeutic. However, the influence of cardiac catheterization on clinical outcomes in this patient population has not been clearly defined. METHODS A single institution, retrospective review of all pediatric cardiac ECLS patients who underwent cardiac catheterization between January 2006 and September 2015 was performed. RESULTS Eighty-two interventional cardiac catheterization procedures were performed on 74 patients. Catheterization findings directly led to catheterization-based or surgical intervention in 54 (73%) patients. One (1.2%) catheterization-related complication occurred (pulmonary artery rupture), which ultimately resulted in death. Patients who underwent early catheterization (≤72 hours of ECLS initiation) required shorter total duration of ECLS than patients who underwent catheterization >72 hours after ECLS initiation (136 hours vs. 227 hours, P < 0.01). The groups experienced similar rates of interventions based on catheterization findings (72% early cath vs. 74% late cath, P = 0.81). Survival to hospital discharge was higher in the early catheterization group (74% vs. 51%, P = 0.04). In multivariate models adjusting for covariates, early catheterization was associated with a reduction in ECLS duration by approximately 150 hours (P < 0.01). CONCLUSIONS Cardiac catheterization is safe in pediatric ECLS patients and an earlier catheterization is associated with shorter duration of ECLS and improved hospital survival. Diagnostic cardiac catheterization should be considered in patients who remain dependent on ECLS after several days of support.
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Affiliation(s)
- Christopher R Burke
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington
| | - Titus Chan
- Division of Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Agustin E Rubio
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington
| | - David M McMullan
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington
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