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Moynihan KM, Sharma M, Mehta A, Lillie J, Ziegenfuss M, Festa M, Chan T, Thiagarajan R. Race-Conscious Research Using Extracorporeal Life Support Organization Registry Data: A Narrative Review. ASAIO J 2024; 70:721-733. [PMID: 38648078 PMCID: PMC11356683 DOI: 10.1097/mat.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Race-conscious research identifies health disparities with 1) rigorous and responsible data collection, 2) intentionality and considered analyses, and 3) interpretation of results that advance health equity. Individual registries must overcome specific challenges to promote race-conscious research, and this paper describes ways to achieve this with a focus on the international Extracorporeal Life Support Organization (ELSO) registry. This article reviews ELSO registry publications that studied race with outcomes to consider whether research outputs align with race-conscious concepts and describe the direction of associations reported. Studies were identified via secondary analysis of a comprehensive scoping review on ECMO disparities. Of 32 multicenter publications, two (6%) studied race as the primary objective. Statistical analyses, confounder adjustment, and inclusive, antibiased language were inconsistently used. Only two (6%) papers explicitly discussed mechanistic drivers of inequity such as structural racism, and five (16%) discussed race variable limitations or acknowledged unmeasured confounders. Extracorporeal Life Support Organization registry publications demonstrated more adverse ECMO outcomes for underrepresented/minoritized populations than non-ELSO studies. With the objective to promote race-conscious ELSO registry research outputs, we provide a comprehensive understanding of race variable limitations, suggest reasoned retrospective analytic approaches, offer ways to interpret results that advance health equity, and recommend practice modifications for data collection.
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Affiliation(s)
- Katie M Moynihan
- From the Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, Massachusetts
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Meesha Sharma
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, California
| | - Anuj Mehta
- Division of Pulmonary and Critical Care Medicine, Department of Medicine Denver Health and Hospital Authority, Denver, Colorado
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jon Lillie
- Pediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Marc Ziegenfuss
- Adult Intensive Care Services, Prince Charles Hospital, Queensland Intensive Care Clinical Network and State Emergency Coordination Centre, Brisbane, Australia
- Australian and New Zealand Intensive Care Society (ANZICS), Australia
| | - Marino Festa
- New South Wales Kids ECMO Referral Service, Australia
- Kids Critical Care Research, Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Titus Chan
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ravi Thiagarajan
- From the Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, Massachusetts
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Moynihan KM, Dorste A, Alizadeh F, Phelps K, Barreto JA, Kolwaite AR, Merlocco A, Barbaro RP, Chan T, Thiagarajan RR. Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature. Crit Care Med 2023; 51:843-860. [PMID: 36975216 DOI: 10.1097/ccm.0000000000005866] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To map the scope, methodological rigor, quality, and direction of associations between social determinants of health (SDoH) and extracorporeal membrane oxygenation (ECMO) utilization or outcomes. DATA SOURCES PubMed, Web of Science, Embase, and Cochrane Library databases were systematically searched for citations from January 2000 to January 2023, examining socioeconomic status (SES), race, ethnicity, hospital and ECMO program characteristics, transport, and geographic location (context) with utilization and outcomes (concept) in ECMO patients (population). STUDY SELECTION Methodology followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review extension. Two reviewers independently evaluated abstracts and full text of identified publications. Exclusion criteria included non-English, unavailable, less than 40 patients, and periprocedural or mixed mechanical support. DATA EXTRACTION Content analysis used a standardized data extraction tool and inductive thematic analysis for author-proposed mediators of disparities. Risk of bias was assessed using the Quality in Prognosis Studies tool. DATA SYNTHESIS Of 8,214 citations screened, 219 studies were identified. Primary analysis focuses on 148 (68%) including race/ethnicity/SES/payer variables including investigation of ECMO outcomes 114 (77%) and utilization 43 (29%). SDoH were the primary predictor in 15 (10%). Overall quality and methodologic rigor was poor with advanced statistics in 7%. Direction of associations between ECMO outcomes or utilization according to race, ethnicity, SES, or payer varied. In 38% adverse outcomes or lower use was reported in underrepresented, under-resourced or diverse populations, while improved outcomes or greater use were observed in these populations in 7%, and 55% had no statistically significant result. Only 26 studies (18%) discussed mechanistic drivers of disparities, primarily focusing on individual- and hospital-level rather than systemic/structural factors. CONCLUSIONS Associations between ECMO utilization and outcomes with SDoH are inconsistent, complicated by population heterogeneity and analytic shortcomings with limited consideration of systemic contributors. Findings and research gaps have implications for measuring, analyzing, and interpreting SDoH in ECMO research and healthcare.
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Affiliation(s)
- Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anna Dorste
- Medical Library, Boston Children's Hospital, Boston, MA
| | - Faraz Alizadeh
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Kayla Phelps
- Department of Pediatrics, Children's Hospital New Orleans, Louisiana State University, New Orleans, LA
| | - Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Amy R Kolwaite
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Anthony Merlocco
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Ryan P Barbaro
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
| | - Titus Chan
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Ravi R Thiagarajan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Fenwick Institute for Pediatric Health Equity and Inclusion, Boston Children's Hospital, Boston, MA
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Geisser DL, Thiagarajan RR, Scholtens D, Kuang A, Petito LC, Costello JM, Monge MC, Di Nardo M, Marino BS. Development of a Model for the Pediatric Survival After Veno-Arterial Extracorporeal Membrane Oxygenation Score: The Pedi-SAVE Score. ASAIO J 2022; 68:1384-1392. [PMID: 35184092 DOI: 10.1097/mat.0000000000001678] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Pediatric cardiac extracorporeal membrane oxygenation (ECMO) patients have high mortality rates. The purpose of our study was to develop and validate the Pediatric Survival After Veno-arterial ECMO (Pedi-SAVE) score for predicting survival at hospital discharge after pediatric cardiac veno-arterial (VA) ECMO. We used data for pediatric cardiac VA-ECMO patients from the Extracorporeal Life Support Organization registry (1/1/2001-12/31/2015). Development and validation cohorts were created using 2:1 random sampling. Predictors of survival to develop pre- and postcannulation models were selected using multivariable logistic regression and random forest models. ß-coefficients were standardized to create the Pedi-SAVE score. Of 10,091 pediatric cardiac VA-ECMO patients, 4,996 (50%) survived to hospital discharge. Pre- and postcannulation Pedi-SAVE scores predicted that the lowest risk patients have a 65% and 74% chance of survival at hospital discharge, respectively, compared to 33% and 22% in the highest risk patients. In the validation cohort, pre- and postcannulation Pedi-SAVE scores had c-statistics of 0.64 and 0.71, respectively. Precannulation factors associated with survival included: nonsingle ventricle congenital heart disease, older age, white race, lower STAT mortality category, higher pH, not requiring acid-buffer administration, <2 cardiac procedures, and indication for VA-ECMO other than failure to wean from cardiopulmonary bypass. Postcannulation, additional factors associated with survival included: lower ECMO pump flows at 24 hours and lack of complications. The Pedi-SAVE score is a novel validated tool to predict survival at hospital discharge for pediatric cardiac VA-ECMO patients, and is an important advancement in risk adjustment and benchmarking for this population.
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Affiliation(s)
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Denise Scholtens
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alan Kuang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lucia C Petito
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John M Costello
- Department of Pediatrics, Shaun Jenkins Children's Hospital, Medical University of South Carolina, Charleston, South Carolina
| | - Michael C Monge
- Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Bradley S Marino
- From the Division of Cardiology.,Division of Critical Care Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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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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Cho HJ, Choi I, Kwak Y, Kim DW, Habimana R, Jeong IS. The Outcome of Post-cardiotomy Extracorporeal Membrane Oxygenation in Neonates and Pediatric Patients: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:869283. [PMID: 35547551 PMCID: PMC9083359 DOI: 10.3389/fped.2022.869283] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Post-cardiotomy extracorporeal membrane oxygenation (PC-ECMO) is a known rescue therapy for neonates and pediatric patients who failed to wean from cardiopulmonary bypass (CPB) or who deteriorate in intensive care unit (ICU) due to various reasons such as low cardiac output syndrome (LCOS), cardiac arrest and respiratory failure. We conducted a systematic review and meta-analysis to assess the survival in neonates and pediatric patients who require PC-ECMO and sought the difference in survivals by each indication for PC-ECMO. DESIGN Systematic review and meta-analysis. SETTING Multi-institutional analysis. PARTICIPANTS Neonates and pediatric patients who requires PC- ECMO. INTERVENTIONS ECMO after open-heart surgery. RESULTS Twenty-six studies were included in the analysis with a total of 186,648 patients and the proportion of the population who underwent PC-ECMO was 2.5% (2,683 patients). The overall pooled proportion of survival in this population was 43.3% [95% Confidence interval (CI): 41.3-45.3%; I 2: 1%]. The survival by indications of PC-ECMO were 44.6% (95% CI: 42.6-46.6; I 2: 0%) for CPB weaning failure, 47.3% (95% CI: 39.9-54.7%; I 2: 5%) for LCOS, 37.6% (95% CI: 31.0-44.3%; I 2: 32%) for cardiac arrest and 47.7% (95% CI: 32.5-63.1%; I 2: 0%) for respiratory failure. Survival from PC-ECMO for single ventricle or biventricular physiology, was reported by 12 studies. The risk ratio (RR) was 0.74 for survival in patients with single ventricle physiology (95% CI: 0.63-0.86; I 2: 40%, P < 0.001). Eight studies reported on the survival after PC-ECMO for genetic conditions. The RR was 0.93 for survival in patients with genetic condition (95% CI: 0.52-1.65; I 2: 65%, P = 0.812). CONCLUSIONS PC-ECMO is an effective modality to support neonates and pediatric patients in case of failed CPB weaning and deterioration in ICU. Even though ECMO seems to improve survival, mortality and morbidity remain high, especially in neonates and pediatric patients with single ventricle physiology. Most genetic conditions alone should not be considered a contraindication to ECMO support, further studies are needed to determine which genetic abnormalities are associated with favorable outcome.
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Affiliation(s)
- Hwa Jin Cho
- Division of Pediatric Cardiology and Cardiac Critical Care, Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea.,Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea
| | - Insu Choi
- Division of Pediatric Cardiology and Cardiac Critical Care, Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea
| | - Yujin Kwak
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Do Wan Kim
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Reverien Habimana
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Biomedical Sciences, College of Medicine, Chonnam National University Graduate School, Gwangju, South Korea
| | - In-Seok Jeong
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
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Brown G, Moynihan KM, Deatrick KB, Hoskote A, Sandhu HS, Aganga D, Deshpande SR, Menon AP, Rozen T, Raman L, Alexander PMA. Extracorporeal Life Support Organization (ELSO): Guidelines for Pediatric Cardiac Failure. ASAIO J 2021; 67:463-475. [PMID: 33788796 DOI: 10.1097/mat.0000000000001431] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
These guidelines are applicable to neonates and children with cardiac failure as indication for extracorporeal life support. These guidelines address patient selection, management during extracorporeal membrane oxygenation, and pathways for weaning support or bridging to other therapies. Equally important issues, such as personnel, training, credentialing, resources, follow-up, reporting, and quality assurance, are addressed in other Extracorporeal Life Support Organization documents or are center-specific.
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Affiliation(s)
- Georgia Brown
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Hitesh S Sandhu
- Department of Pediatrics, Critical Care Division, Le Bonheur Children's Hospital, University of Tennessee, Memphis, Tennessee
| | - Devon Aganga
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shriprasad R Deshpande
- Pediatric Cardiology Division, Heart Transplant and Advanced Cardiac Therapies Program, Children's National Heart Institute, Washington, D.C
| | - Anuradha P Menon
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Thomas Rozen
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Lakshmi Raman
- Department of Critical Care, University of Texas Southwestern Medical Center, Texas
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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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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8
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Right Atrial Cannulation via Thoracotomy for Emergent Extracorporeal Membrane Oxygenation in Pediatric Patients with Prior Sternotomy. ASAIO J 2021; 67:e64-e68. [PMID: 32404614 DOI: 10.1097/mat.0000000000001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is the most common mechanical circulatory support strategy used to treat pediatric patients presenting with low cardiac output or cardiogenic shock. While transthoracic central cannulation is feasible and mostly utilized for early postoperative support, peripheral cannulation is preferred as a primary strategy in the late postoperative period. Redo-sternotomy and venous cannulation are difficult to achieve in patients with occluded peripheral veins or complex venous anatomy like Glenn circulation. In pediatric patients with multiple prior sternotomy and catheterization procedures, vascular access for cannulation is frequently limited. Peripheral cannulation for venoarterial ECMO (VA-ECMO) may be challenging or even impossible. In our case series, four pediatric patients with prior sternotomy underwent right atrial cannulation emergently in patients to secure venous drainage for ECMO support. Extracorporeal membrane oxygenation support could be established rapidly with adequate venous drainage in all cases. We conclude that right atrial cannulation via right thoracotomy can be a useful technique for venous cannulation in cases with prior sternotomy and is particularly useful in cases with Glenn circulation.
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Stephens EH, Shakoor A, Jacobs SE, Okochi S, Zenilman AL, Middlesworth W, Kalfa D, Chai PJ, Chaves DV, Bacha E, Cheung EW. Characterization of Extracorporeal Membrane Oxygenation Support for Single Ventricle Patients. World J Pediatr Congenit Heart Surg 2020; 11:183-191. [PMID: 32093561 DOI: 10.1177/2150135119894294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) can provide crucial support for single ventricle (SV) patients at various stages of palliation. However, characterization of the utilization and outcomes of ECMO in these unique patients remains incompletely studied. METHODS We performed a single-center retrospective review of SV patients between 2010 and 2017 who underwent ECMO cannulation with primary end point of survival to discharge and secondary end point of survival to decannulation or orthotopic heart transplantation (OHT). Multivariate analysis was performed for factors predictive of survival to discharge and survival to decannulation. RESULTS Forty SV patients with a median age of one month (range: 3 days to 15 years) received ECMO support. The incidence of ECMO was 14% for stage I, 3% for stage II, and 4% for stage III. Twenty-seven (68%) patients survived to decannulation, and 21 (53%) patients survived to discharge, with seven survivors to discharge undergoing OHT. Complications included infection (40%), bleeding (40%), thrombosis (33%), and radiographic stroke (45%). Factors associated with survival to decannulation included pre-ECMO lactate (hazard ratio [HR]: 0.61, 95% confidence interval [CI]: 0.41-0.90, P = .013) and post-ECMO bicarbonate (HR: 1.24, 95% CI: 1.0-1.5, P = .018). Factors associated with survival to discharge included central cannulation (HR: 40.0, 95% CI: 3.1-500.0, P = .005) and lack of thrombotic complications (HR: 28.7, 95% CI: 2.1-382.9, P = .011). CONCLUSIONS Extracorporeal membrane oxygenation can be useful to rescue SV patients with approximately half surviving to discharge, although complications are frequent. Early recognition of the role of heart transplant is imperative. Further study is required to identify areas for improvement in this population.
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Affiliation(s)
- Elizabeth H Stephens
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Congenital and Pediatric Cardiac Surgery, Columbia University Medical Center, New York, NY, USA
| | - Aqsa Shakoor
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Pediatric Surgery, Columbia University Medical Center, New York, NY, USA
| | - Shimon E Jacobs
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Pediatric Surgery, Columbia University Medical Center, New York, NY, USA
| | - Shunpei Okochi
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Pediatric Surgery, Columbia University Medical Center, New York, NY, USA
| | - Ariela L Zenilman
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Pediatric Surgery, Columbia University Medical Center, New York, NY, USA
| | - William Middlesworth
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Pediatric Surgery, Columbia University Medical Center, New York, NY, USA
| | - David Kalfa
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Congenital and Pediatric Cardiac Surgery, Columbia University Medical Center, New York, NY, USA
| | - Paul J Chai
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Congenital and Pediatric Cardiac Surgery, Columbia University Medical Center, New York, NY, USA
| | - Diana Vargas Chaves
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Neonatalogy, Columbia University Medical Center, New York, NY, USA
| | - Emile Bacha
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Congenital and Pediatric Cardiac Surgery, Columbia University Medical Center, New York, NY, USA
| | - Eva W Cheung
- NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.,Pediatric Cardiac Critical Care, Columbia University Medical Center, New York, NY, USA
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Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, Ong GYK, Reis AG, Schexnayder SM, Scholefield BR, Tijssen JA, Nolan JP, Morley PT, Van de Voorde P, Zaritsky AL, de Caen AR. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A120-A155. [PMID: 33098916 PMCID: PMC7576321 DOI: 10.1016/j.resuscitation.2020.09.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.
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Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S469-S523. [PMID: 33081526 DOI: 10.1161/cir.0000000000000901] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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12
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Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, Ong GYK, Reis AG, Schexnayder SM, Scholefield BR, Tijssen JA, Nolan JP, Morley PT, Van de Voorde P, Zaritsky AL, de Caen AR. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S140-S184. [PMID: 33084393 DOI: 10.1161/cir.0000000000000894] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.
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13
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Choi RS, DiNardo JA, Brown ML. Superior Cavopulmonary Connection: Its Physiology, Limitations, and Anesthetic Implications. Semin Cardiothorac Vasc Anesth 2020; 24:337-348. [PMID: 32646291 DOI: 10.1177/1089253220939361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The superior cavopulmonary connection (SCPC) or "bidirectional Glenn" is an integral, intermediate stage in palliation of single ventricle patients to the Fontan procedure. The procedure, normally performed at 3 to 6 months of life, increases effective pulmonary blood flow and reduces the ventricular volume load in patients with single ventricle (parallel circulation) physiology. While the SCPC, with or without additional sources of pulmonary blood flow, cannot be considered a long-term palliation strategy, there are a subset of patients who require SCPC palliation for a longer interval than the typical patient. In this article, we will review the physiology of SCPC, the consequences of prolonged SCPC palliation, and modes of failure. We will also discuss strategies to augment pulmonary blood flow in the presence of an SCPC. The anesthetic considerations in SCPC patients will also be discussed, as these patients may present for noncardiac surgery from infancy to adulthood.
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Affiliation(s)
- Ray S Choi
- Children's Hospital Colorado, Denver, CO, USA.,Boston Children's Hospital, Boston, MA, USA
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14
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Hames DL, Mills KI, Thiagarajan RR, Teele SA. Extracorporeal Membrane Oxygenation in Infants Undergoing Truncus Arteriosus Repair. Ann Thorac Surg 2020; 111:176-183. [PMID: 32335016 DOI: 10.1016/j.athoracsur.2020.03.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Infants undergoing truncus arteriosus (TA) repair suffer one of the highest mortality rates of all congenital heart defects. Extracorporeal membrane oxygenation (ECMO) can support patients undergoing TA repair, but little is known about factors contributing to mortality in this cohort. The objective of this study was to identify risk factors for mortality in infants with TA requiring perioperative ECMO. METHODS Data from the Extracorporeal Life Support Organization from 2002 to 2017 for infants less than 60 days old undergoing TA repair were analyzed. Demographics, clinical characteristics, and ECMO characteristics and complications were compared between survivors and nonsurvivors. Multivariable logistic regression was used to evaluate independent risk factors for mortality. RESULTS Of 245 patients analyzed, 92 (37.6%) survived to discharge. Nonsurvivors had a lower weight and a longer ECMO duration. A higher proportion of nonsurvivors suffered complications on ECMO, including mechanical complications, circuit thrombus, bleeding, and need for renal replacement therapy. In multivariable analysis lower weight (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.95), duration of ECMO (OR, 1.1; 95% CI, 1.02-1.18), need for renal replacement therapy (OR, 3.23; 95% CI, 1.68-6.2), cardiopulmonary resuscitation on ECMO (OR, 11.52; 95% CI, 1.3-102.33), and infection on ECMO (OR, 4.47; 95% CI, 1.2-16.64) were independently associated with mortality. CONCLUSIONS Many factors associated with mortality for infants requiring perioperative ECMO with TA repair are related to complications suffered on ECMO. Thoughtful patient selection and meticulous ECMO management to prevent complications are essential in improving outcomes for these infants.
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Affiliation(s)
- Daniel L Hames
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Kimberly I Mills
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ravi R Thiagarajan
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sarah A Teele
- Department of Cardiology, Division of Cardiovascular Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Matic T, Bakos M, Belina D, Duric Z, Bartonicek D, Malcic I. Extracorporeal Membrane Oxygenation After Glenn Procedure in a Child With Influenza B Pneumonia. World J Pediatr Congenit Heart Surg 2020; 11:370-371. [PMID: 32294017 DOI: 10.1177/2150135119899619] [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
A five-month-old male with a hypoplastic left heart syndrome developed severe respiratory insufficiency due to influenza type B viral pneumonia following bidirectional Glenn. He was treated with extracorporeal membrane oxygenation and successfully weaned without neurological consequences.
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Affiliation(s)
- Toni Matic
- Department of Pediatrics, University Hospital Centre Zagreb, Kispaticeva, Zagreb, Croatia
| | - Matija Bakos
- Department of Pediatrics, University Hospital Centre Zagreb, Kispaticeva, Zagreb, Croatia
| | - Drazen Belina
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Kispaticeva, Zagreb, Croatia
| | - Zeljko Duric
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Kispaticeva, Zagreb, Croatia.,Department of Surgery, Special Hospital for Cardiovascular Disease Magdalena, Ljudevita Gaja, Krapinske Toplice, Croatia
| | - Dorotea Bartonicek
- Department of Pediatrics, University Hospital Centre Zagreb, Kispaticeva, Zagreb, Croatia
| | - Ivan Malcic
- Department of Pediatrics, University Hospital Centre Zagreb, Kispaticeva, Zagreb, Croatia
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16
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Haranal M, Luo S, Honjo O. Mechanical Circulatory Support for Patients With Adult Congenital Heart Disease. Circ J 2020; 84:533-541. [DOI: 10.1253/circj.cj-19-0821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Maruti Haranal
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
| | - Shuhua Luo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children
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17
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Ergün S, Yildiz O, Güneş M, Akdeniz HS, Öztürk E, Onan İS, Güzeltaş A, Haydin S. Use of extracorporeal membrane oxygenation in postcardiotomy pediatric patients: parameters affecting survival. Perfusion 2020; 35:608-620. [PMID: 31971070 DOI: 10.1177/0267659119897746] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM We aimed to investigate the risk factors affecting survival after extracorporeal membrane oxygenation use in pediatric postcardiotomy patients. METHODS One hundred thirty-three consecutive patients who underwent surgery for congenital heart disease who needed extracorporeal membrane oxygenation support were retrospectively analyzed. RESULTS In all, 3,082 patients were operated, of which 140 patients (4.54% of the total number of operations) needed extracorporeal membrane oxygenation. Eighty (60.1%) patients were successfully weaned and 51 (38.3%) patients were discharged. Of the 50 patients discharged during the mean follow-up period of 34.8 (0-192.4) months, 6 (12%) patients died. The extracorporeal membrane oxygenation support was instituted in 29 (21.8%) patients for extracorporeal membrane oxygenation cardiopulmonary resuscitation, in 44 (33.1%) patients due to the inability to be separated from cardiopulmonary bypass, in 19 (14.3%) patients due to respiratory failure, and in 41 patients due to low cardiac output syndrome. Eighty patients (60.2%) were successfully weaned from extracorporeal membrane oxygenation support. The remaining 53 (39.8%) patients died on extracorporeal membrane oxygenation. Mortality was observed in 29 (21.8%) of the 80 patients in the successful weaning group, while the remaining 51 (38.3%) patients were discharged from the hospital. Multivariate analysis showed that double-ventricular physiology increased the rate of successful weaning (odds ratio: 3.4, 95% confidence interval lower: 1.5 and upper: 8, p = 0.004) and prolonged extracorporeal membrane oxygenation durations were a risk factor in successful weaning (odds ratio: 0.9, 95% confidence interval lower: 0.8 and upper: 0.9, p = 0.007). The parameters affecting mortality were the presence of syndrome (odds ratio: 3.8, 95% confidence interval lower: 1.0 and upper: 14.9, p = 0.05), single-ventricular physiology (odds ratio: 5.3, 95% confidence interval lower: 1.8 and upper: 15.3, p = 0.002), and the need for a second extracorporeal membrane oxygenation (odds ratio: 12.9, 95% confidence interval lower: 1.6 and upper: 104.2, p = 0.02). While 1-year survival was 15.2% and 3-year survival was 12.1% in patients with single-ventricular physiology, the respective survival rates were 43.9% and 40.8%. CONCLUSION Parameters affecting mortality after extracorporeal membrane oxygenation support in pediatric postcardiotomy patient group were the presence of a syndrome, multiple runs of extracorporeal membrane oxygenation, and single-ventricular physiology. Timing of extracorporeal membrane oxygenation initiation, appropriate patient selection, appropriate reintervention or reoperation for patients with correctable pathology, the use of an appropriate cannulation strategy in single-ventricle patients, management of shunt flow, and appropriate interventions to reduce the incidence of complications play key roles in improving survival.
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Affiliation(s)
- Servet Ergün
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Okan Yildiz
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Mustafa Güneş
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Halil Sencer Akdeniz
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Erkut Öztürk
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - İsmihan Selen Onan
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Alper Güzeltaş
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Sertaç Haydin
- Department of Cardiovascular Surgery, Istanbul Saglik Bilimleri University Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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18
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Shah M, Lin KY. Failure (at any stage) and the role of mechanical circulatory support in hypoplastic left heart syndrome. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2019.101134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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19
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Lorusso R, Raffa GM, Kowalewski M, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Dalton H, Barbaro R, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, Oreto L, D'Alessandro DA, Boeken U, Whitman G. Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2-pediatric patients. J Heart Lung Transplant 2019; 38:1144-1161. [PMID: 31421976 DOI: 10.1016/j.healun.2019.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 06/19/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, veno-venous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy.
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Khalid Alenizy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Niels Sluijpers
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maged Makhoul
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Brodie
- Division of Pulmonary & Critical Care Medicine, Columbia University, New York, New York
| | - Mike McMullan
- Cardiac Surgery Unit, Seattle Children Hospital, Seattle, Washington
| | - I-Wen Wang
- Cardiac Transplantation and Mechanical Circulatory Support Unit, Indiana University School of Medicine, Health Methodist Hospital, Indianapolis, Indiana
| | - Paolo Meani
- Heart & Vascular Centre, Cardiology Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University of Singapore, Singapore
| | - Heidi Dalton
- INOVA Fairfax Medical Centre, Adult and Pediatric ECMO Service, Falls Church, Virginia
| | - Ryan Barbaro
- Division of Pediatric Critical Care and Child Health Evaluation and Research Unit, Ann Arbor, Michigan
| | - Xaotong Hou
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nicholas Cavarocchi
- Surgical Cardiac Care Unit, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Ped Cardiovascular Surgery, National Taiwan University Hospital, Taipei, China
| | - Ravi Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
| | - Peta Alexander
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lilia Oreto
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Pediatric Hospital, Taormina, Messina, Italy
| | - David A D'Alessandro
- Cardio-Thoracic Surgery Department, Massachusetts Medical Center, Boston, Massachusetts
| | - Udo Boeken
- Cardiovascular Surgery Unit, University of Düsseldorf, Düsseldorf, Germany
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit and Heart Transplant, Johns Hopkins Hospital, Baltimore, Maryland
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20
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Yoneyama F, Okamura T. Quick atrial access by subxiphoid approach in extracorporeal cardiopulmonary resuscitation after bidirectional Glenn procedure. Perfusion 2019; 34:425-427. [PMID: 30636532 DOI: 10.1177/0267659118823999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Bidirectional Glenn procedure outcomes are very good; therefore, extracorporeal membrane oxygenation use as extracorporeal cardiopulmonary resuscitation is uncommon. We describe a 13-month-old female who required extracorporeal cardiopulmonary resuscitation for ventricular tachycardia provoked by transient myocarditis 6 months post-bidirectional Glenn procedure. After extracorporeal membrane oxygenation induction with cannulation on the cervical vessels, small skin incision was created on the subxiphoid area without sternotomy and the atrium was cannulated. With adequate venous drainage and ventricular unloading, ventricular tachycardia eventually converted to sinus rhythm. The patient withdrew from extracorporeal membrane oxygenation and was discharged successfully. Our results suggest that for successful post-bidirectional Glenn extracorporeal cardiopulmonary resuscitation, quick atrial access and ventricular unloading are essential.
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Affiliation(s)
- Fumiya Yoneyama
- Department of Cardiovascular Surgery, Nagano Children's Hospital, Azumino, Japan
| | - Toru Okamura
- Department of Cardiovascular Surgery, Nagano Children's Hospital, Azumino, Japan
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21
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Abstract
The care of children with hypoplastic left heart syndrome is constantly evolving. Prenatal diagnosis of hypoplastic left heart syndrome will aid in counselling of parents, and selected fetuses may be candidates for in utero intervention. Following birth, palliation can be undertaken through staged operations: Norwood (or hybrid) in the 1st week of life, superior cavopulmonary connection at 4-6 months of life, and finally total cavopulmonary connection (Fontan) at 2-4 years of age. Children with hypoplastic left heart syndrome are at risk of circulatory failure their entire life, and selected patients may undergo heart transplantation. In this review article, we summarise recent advances in the critical care management of patients with hypoplastic left heart syndrome as were discussed in a focused session at the 12th International Conference of the Paediatric Cardiac Intensive Care Society held on 9 December, 2016, in Miami Beach, Florida.
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22
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Griselli M, Sinha R, Jang S, Perri G, Adachi I. Mechanical Circulatory Support for Single Ventricle Failure. Front Cardiovasc Med 2018; 5:115. [PMID: 30211172 PMCID: PMC6122112 DOI: 10.3389/fcvm.2018.00115] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/07/2018] [Indexed: 12/21/2022] Open
Abstract
Mechanical circulatory support (MCS) for failing single ventricle (SV) physiology is a complex and challenging problem, which has not yet been satisfactorily addressed. Advancements in surgical strategies and techniques along with intensive care management have substantially improved the outcomes of neonatal palliation for SV physiology, particularly for hypoplastic left heart syndrome (HLHS). This is associated with a steady increase in the number of SV patients who are susceptible to develop heart failure (HF) and would potentially require MCS at a certain stage in their palliation. We have reviewed the literature regarding the reported modalities of MCS use in the management of SV patients. This includes analysis of various devices and strategies used for failing circulation at distinct stages of the SV pathway: after neonatal palliation, after the superior cavo-pulmonary connection (SCPC), and after total cavo-pulmonary connection (TCPC).
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Affiliation(s)
- Massimo Griselli
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Raina Sinha
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Subin Jang
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Gianluigi Perri
- Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Iki Adachi
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
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23
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Extracorporeal membrane oxygenation, Berlin, and ventricular assist devices: a primer for the cardiologist. Curr Opin Cardiol 2018; 33:87-94. [PMID: 29059075 DOI: 10.1097/hco.0000000000000479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mechanical circulatory support (MCS) has become an indispensable tool in the management of children with impending respiratory and cardiac failure. Though extracorporeal membrane oxygenation (ECMO) was classically the only form of support available to pediatric patients, considerable advances have allowed ventricular assist devices (VADs) to become increasingly utilized in children. This review provides an update of recent advances in ECMO and VAD management in children. RECENT FINDINGS The options for mechanical support in infants and small children with end-stage heart failure are limited. As such, the greatest advances in the past decade have come in the successful adoption of the Berlin Heart EXCOR device, with a marked improvement in survival to transplant over ECMO. Further advances have been made in the use of adult VADs in children. For instance, the HeartWare HVAD has been utilized in children as young as 3 years of age, despite being designed for use in adult patients. SUMMARY The availability of mechanical support options for children remains limited to ECMO and a small number of VADs. While outcomes of VAD support in pediatric patients have been promising, further study in smaller and more complex pediatric patients is necessary.
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24
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Cua CL, McConnell PI, Meza JM, Hill KD, Zhang S, Hersey D, Karamlou T, Jacobs JP, Jacobs ML, Galantowicz M. Hybrid Palliation: Outcomes After the Comprehensive Stage 2 Procedure. Ann Thorac Surg 2018; 105:1455-1460. [DOI: 10.1016/j.athoracsur.2017.11.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 10/17/2017] [Accepted: 11/10/2017] [Indexed: 12/20/2022]
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25
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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26
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Bacon MK, Gray SB, Schwartz SM, Cooper DS. Extracorporeal Membrane Oxygenation (ECMO) Support in Special Patient Populations-The Bidirectional Glenn and Fontan Circulations. Front Pediatr 2018; 6:299. [PMID: 30386759 PMCID: PMC6199392 DOI: 10.3389/fped.2018.00299] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/25/2018] [Indexed: 01/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a support modality used within the pediatric cardiac ICU population as a bridge to recovery or decision in the setting of acute myocardial decompensation, support for combined cardiopulmonary failure or in the setting of refractory cardiopulmonary arrest. Patients with univentricular physiology are at particular risk for decompensation requiring ECMO support. This review will focus upon current evidence and techniques for ECMO support of single ventricle patients who have undergone a stage II bidirectional Glenn procedure or the stage III Fontan procedure.
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Affiliation(s)
- Matthew K Bacon
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Seth B Gray
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Steven M Schwartz
- Departments of Critical Care Medicine and Pediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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27
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Harvey C. Cannulation for Neonatal and Pediatric Extracorporeal Membrane Oxygenation for Cardiac Support. Front Pediatr 2018; 6:17. [PMID: 29616201 PMCID: PMC5868139 DOI: 10.3389/fped.2018.00017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/17/2018] [Indexed: 11/18/2022] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) has increased over recent years providing respiratory and cardiac support. Optimal cannula placement is essential for successful patient outcomes. Multiple cannulation strategies may be employed depending on the age/weight of the patient and their underlying condition. This article discusses cannulation technique focusing on the cannulation of pediatric and neonatal patients for cardiac support on ECMO.
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Affiliation(s)
- Chris Harvey
- University Hospitals of Leicester, Leicester, United Kingdom
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Xie A, Lo P, Yan TD, Forrest P. Neurologic Complications of Extracorporeal Membrane Oxygenation: A Review. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.03.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Burki S, Adachi I. Pediatric ventricular assist devices: current challenges and future prospects. Vasc Health Risk Manag 2017; 13:177-185. [PMID: 28546755 PMCID: PMC5437969 DOI: 10.2147/vhrm.s82379] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The field of mechanical circulatory support has made great strides in the preceding 2 decades. Although pediatric mechanical circulatory support has lagged behind that of adults, the gap between them is expected to close soon. The only device currently approved by the US Food and Drug Administration for use in children is the Berlin Heart EXCOR ventricular assist device (VAD). The prospective Berlin Heart Investigational Device Exemption Trial demonstrated good outcomes, such as bridge to transplantation or recovery, in ~90% of children supported with this device. However, a high incidence of hemorrhagic and thrombotic complications was also noted. As a result, pediatric centers have just started implanting adult intracorporeal continuous-flow devices in children. This paradigm shift has opened a new era in pediatric mechanical circulatory support. Whereas children on VAD were previously managed exclusively in hospital, therapeutic options such as outpatient management and even destination therapy have been becoming a reality. With continued miniaturization and technological refinements, devices currently in development will broaden the range of options available to children. The HeartMate 3 and HeartWare MVAD are two such compact VADs, which are anticipated to have great potential for pediatric use. Additionally, a pediatric-specific continuous-flow VAD, the newly redesigned Jarvik Infant 2015, is currently undergoing preclinical testing and is expected to undergo a randomized clinical trial in the near future. This review aims to discuss the challenges posed by the use of intracorporeal adult continuous-flow devices in children, as well as to provide our perspective on the future prospects of the field of pediatric VADs.
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Affiliation(s)
- Sarah Burki
- Division of Congenital Heart Surgery, Texas Children's Hospital.,Department of Surgery and Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Texas Children's Hospital.,Department of Surgery and Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Adachi I, Burki S, Fraser CD. Current Status of Pediatric Ventricular Assist Device Support. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017; 20:2-8. [PMID: 28007059 DOI: 10.1053/j.pcsu.2016.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 09/16/2016] [Accepted: 09/19/2016] [Indexed: 06/06/2023]
Abstract
The last decade has witnessed significant advancement in the field of ventricular assist device (VAD) support. Although device options for pediatric patients were previously severely limited because of body size constraints, this frustrating situation has gradually been changing, owing to ongoing device miniaturization. Recognition of the superiority of VAD support compared with conventional extracorporeal membrane oxygenation support has spurred enthusiasm for VAD support in children. In this article, we discuss the current status of pediatric VAD support; where do we stand now and where will we be heading? Because this field is rapidly changing, it is anticipated that this article will provide a general overview of what is currently occurring in the field of pediatric VAD support.
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Affiliation(s)
- Iki Adachi
- Congenital Heart Surgery, Texas Children's Hospital; and Assistant Professor, Department of Surgery and Pediatrics, Baylor College of Medicine, Houston, TX.
| | - Sarah Burki
- Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Charles D Fraser
- Chief, Congenital Heart Surgery, Donovan Chair, Texas Children's Hospital; and Susan V. Clayton Chair, Professor of Surgery and Pediatrics, Baylor College of Medicine, Houston, TX
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Cashen K, Hollis TK, Delius RE, Meert KL. Extracorporeal membrane oxygenation for pediatric cardiac failure: Review with a focus on unique subgroups. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Gomez D, Duffy V, Hersey D, Backes C, Rycus P, McConnell P, Voss J, Galantowicz M, Cua CL. Extracorporeal Membrane Oxygenation Outcomes After the Comprehensive Stage II Procedure in Patients With Single Ventricles. Artif Organs 2016; 41:66-70. [DOI: 10.1111/aor.12810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/02/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel Gomez
- The Heart Center; Nationwide Children's Hospital; Columbus OH
| | - Vicky Duffy
- The Heart Center; Nationwide Children's Hospital; Columbus OH
| | - Diane Hersey
- The Heart Center; Nationwide Children's Hospital; Columbus OH
| | - Carl Backes
- The Heart Center; Nationwide Children's Hospital; Columbus OH
| | - Peter Rycus
- Extracorporeal Life Support Organization; Ann Arbor MI USA
| | | | - Jordan Voss
- The Heart Center; Nationwide Children's Hospital; Columbus OH
| | | | - Clifford L. Cua
- The Heart Center; Nationwide Children's Hospital; Columbus OH
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Abstract
OBJECTIVES The Pediatric Advanced Life Support recommendations were developed for otherwise healthy infants and children with normal cardiac anatomy. Patients with acquired and congenital heart disease require specific considerations that may differ from the Pediatric Advanced Life Support recommendations. Our aim is to present prearrest, arrest, and postarrest considerations that are unique to children with congenital and acquired heart disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION A clear understanding of the underlying anatomy and physiology of congenital and acquired heart disease is imperative in order to employ the appropriate modifications to the current Pediatric Advanced Life Support recommendations and to optimize outcomes.
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Abstract
OBJECTIVES The objectives of this review are to discuss the use of extracorporeal membrane oxygenation following surgery for congenital heart disease, myocarditis and as a bridge to cardiac transplantation. In addition, the latest in circuit equipment, the management of anticoagulation and blood transfusions, and short- and long-term outcomes are reviewed. DATA SOURCE MEDLINE, PubMed. CONCLUSIONS The use of extracorporeal membrane oxygenation to support children with heart disease is increasing. There is wide variability in the use and management of extracorporeal membrane oxygenation between centers. Many areas of extracorporeal membrane oxygenation management warrant additional research to inform clinical practice and improve patient outcomes, including the use of extracorporeal membrane oxygenation in patients undergoing single ventricle palliation, optimizing strategies for monitoring and titrating anticoagulation therapies, and efforts directed at minimizing the risk of neurologic injury.
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Aydin SI, Duffy M, Rodriguez D, Rycus PT, Friedman P, Thiagarajan RR, Weinstein S. Venovenous extracorporeal membrane oxygenation for patients with single-ventricle anatomy: A registry report. J Thorac Cardiovasc Surg 2016; 151:1730-6. [DOI: 10.1016/j.jtcvs.2015.12.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 12/04/2015] [Accepted: 12/13/2015] [Indexed: 10/22/2022]
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Karamlou T. Venovenous extracorporeal membrane oxygenation for patients with single-ventricle anatomy: A registry report. J Thorac Cardiovasc Surg 2016; 151:1446-7. [PMID: 27207118 DOI: 10.1016/j.jtcvs.2016.03.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 03/18/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, University of California, San Francisco, Benioff Children's Hospital, San Francisco, Calif.
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Abstract
Limited vascular access because of vessel injury or thrombosis may complicate care of children with congenital heart disease. Although transhepatic venous access for cardiac catheterization and central venous catheter placement has been used in children, its use for extracorporeal membrane oxygenation (ECMO) has not been described. We report successful use of transhepatic cannulation for venovenous ECMO to support a 15 month-old child with bidirectional Glenn anatomy and intractable hypoxemia.
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Is There a Concerning Trend in Extracorporeal Life Support Utilization for Single-Ventricle Patients? Pediatr Crit Care Med 2016; 17:259-60. [PMID: 26945198 DOI: 10.1097/pcc.0000000000000647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The domain of pediatric ventricular assist device (VAD) has recently gained considerable attention. Despite the fact that, historically, the practice of pediatric mechanical circulatory support (MCS) has lagged behind that of adult patients, this gap between the two groups is narrowing. Currently, the Berlin EXCOR VAD is the only pediatric-specific durable VAD approved by the U.S Food and Drug Administration (FDA). The prospective Berlin Heart trial demonstrated a successful outcome, either bridge to transplantation (BTT), or in rare instances, bridge to recovery, in approximately 90% of children. Also noted during the trial was, however, a high incidence of adverse events such as embolic stroke, bleeding and infection. This has incentivized some pediatric centers to utilize adult implantable continuous-flow devices, for instance the HeartMate II and HeartWare HVAD, in children. As a result of this paradigm shift, the outlook of pediatric VAD support has dramatically changed: Treatment options previously unavailable to children, including outpatient management and even destination therapy, have now been becoming a reality. The sustained demand for continued device miniaturization and technological refinements is anticipated to extend the range of options available to children-HeartMate 3 and HeartWare MVAD are two examples of next generation VADs with potential pediatric application, both of which are presently undergoing clinical trials. A pediatric-specific continuous-flow device is also on the horizon: the redesigned Infant Jarvik VAD (Jarvik 2015) is undergoing pre-clinical testing, with a randomized clinical trial anticipated to follow thereafter. The era of pediatric VADs has begun. In this article, we discuss several important aspects of contemporary VAD therapy, with a particular focus on challenges unique to the pediatric population.
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Affiliation(s)
- Iki Adachi
- 1 Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA ; 2 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Sarah Burki
- 1 Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA ; 2 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Farhan Zafar
- 1 Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA ; 2 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - David Luis Simon Morales
- 1 Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA ; 2 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Nair AB, Oishi P. Venovenous Extracorporeal Life Support in Single-Ventricle Patients with Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:66. [PMID: 27446889 PMCID: PMC4923132 DOI: 10.3389/fped.2016.00066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/01/2016] [Indexed: 02/05/2023] Open
Abstract
There is new and growing experience with venovenous extracorporeal life support (VV ECLS) for neonatal and pediatric patients with single-ventricle physiology and acute respiratory distress syndrome (ARDS). Outcomes in this population have been defined but could be improved; survival rates in single-ventricle patients on VV ECLS for respiratory failure are slightly higher than those in single-ventricle patients on venoarterial ECLS for cardiac failure (48 vs. 32-43%), but are lower than in patients with biventricular anatomy (58-74%). To that end, special consideration is necessary for patients with single-ventricle physiology who require VV ECLS for ARDS. Specifically, ARDS disrupts the balance between pulmonary and systemic blood flow through dynamic alterations in cardiopulmonary mechanics. This complexity impacts how to run the VV ECLS circuit and the transition back to conventional support. Furthermore, these patients have a complicated coagulation profile. Both venous and arterial thrombi carry marked risk in single-ventricle patients due to the vulnerability of the pulmonary, coronary, and cerebral circulations. Finally, single-ventricle palliation requires the preservation of low resistance across the pulmonary circulation, unobstructed venous return, and optimal cardiac performance including valve function. As such, the proper timing as well as the particular conduct of ECLS might differ between this population and patients without single-ventricle physiology. The goal of this review is to summarize the current state of knowledge of VV ECLS in the single-ventricle population in the context of these special considerations.
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Affiliation(s)
- Alison B Nair
- Department of Pediatrics, University of California San Francisco , San Francisco, CA , USA
| | - Peter Oishi
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
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Di Nardo M, MacLaren G, Marano M, Cecchetti C, Bernaschi P, Amodeo A. ECLS in Pediatric Cardiac Patients. Front Pediatr 2016; 4:109. [PMID: 27774445 PMCID: PMC5053996 DOI: 10.3389/fped.2016.00109] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 09/22/2016] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal life support (ECLS) is an important device in the management of children with severe refractory cardiac and or pulmonary failure. Actually, two forms of ECLS are available for neonates and children: extracorporeal membrane oxygenation (ECMO) and use of a ventricular assist device (VAD). Both these techniques have their own advantages and disadvantages. The intra-aortic balloon pump is another ECLS device that has been successfully used in larger children, adolescents, and adults, but has found limited applicability in smaller children. In this review, we will present the "state of art" of ECMO in neonate and children with heart failure. ECMO is commonly used in a variety of settings to provide support to critically ill patients with cardiac disease. However, a strict selection of patients and timing of intervention should be performed to avoid the increase in mortality and morbidity of these patients. Therefore, every attempt should be done to start ECLS "urgently" rather than "emergently," before the presence of dysfunction of end organs or circulatory collapse. Even though exciting progress is being made in the development of VADs for long-term mechanical support in children, ECMO remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation. With the increase in familiarity with ECMO, new indications have been added, such as extracorporeal cardiopulmonary resuscitation (ECPR). The literature supporting ECPR is increasing in children. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Contraindications to ECLS have reduced in the last 5 years and many centers support patients with functionally univentricular circulations. Improved results have been recently achieved in this complex subset of patients.
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Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù , Rome , Italy
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore; Paediatric Intensive Care Unit, Department of Paediatrics, The Royal Children's Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Marco Marano
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù , Rome , Italy
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù , Rome , Italy
| | - Paola Bernaschi
- Microbiology Unit, Children's Hospital Bambino Gesù , Rome , Italy
| | - Antonio Amodeo
- ECMO and VAD Unit, Children's Hospital Bambino Gesù , Rome , Italy
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Horne D, Conway J, Rebeyka IM, Buchholz H. Mechanical circulatory support in univentricular hearts: current management. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2015; 18:17-24. [PMID: 25939838 DOI: 10.1053/j.pcsu.2015.02.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Failing single-ventricle patients have now come into focus as the next cohort where improvement in outcomes for mechanical circulatory support can be realized. There is a paucity of published patient reports or management protocols in this patient population. Increased interest exists in finding answers of how to bridge these patients to transplant. We review the current literature and describe our approach to the patient with univentricular heart needing mechanical circulatory support.
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Affiliation(s)
- David Horne
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada.
| | - Jennifer Conway
- Division of Pediatric Cardiology, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
| | - Ivan M Rebeyka
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
| | - Holger Buchholz
- Division of Cardiac Surgery, University of Alberta, Stollery Children׳s Hospital, Edmonton, Alberta, Canada
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