Extracorporeal life support in pediatric patients with heart failure

Extracorporeal membrane oxygenation to cardiopulmonary bypass with a single circuit exposure

Due to the short supply of donor organs available, many patients decompensate or die while waiting for transplantation. Options for mechanical support for infants and pediatrics with congenital heart disease are limited because of the patient’s size and device availability. Extracorporeal membrane oxygenation (ECMO) is the most common means of cardiac and respiratory support for these patients. One of the many indications for ECMO use in cardiac patients is as a bridge to transplantation, with patients being transported to the operating room (OR) on ECMO support. Converting the ECMO circuit to an open cardiopulmonary bypass system in the OR minimizes the patient’s exposure to new circuitry, decreases further donor exposures and provides continuous support for patients in cardiac and/or respiratory failure. In addition, the ability to use modified ultrafiltration post-bypass aids in reducing extracellular fluid, increasing the hematocrit and improving hemodynamic stability following an extended duration of ECMO and bypass support. The integrity of the ECMO circuit is maintained and can be converted back to ECMO for support postoperatively if needed.

Extracorporeal life support for treatment of children with enterovirus 71 infection-related cardiopulmonary failure

PURPOSE

Enterovirus 71 (EV71) infection leading to cardiopulmonary failure (CPF) is rare, but usually fatal. In such cases, intensive cardiorespiratory support is essential for survival. In this study, we report our experience in the treatment of EV71-related CPF with extracorporeal life support (ECLS).

METHODS

This was a retrospective study of a total of 13 children, aged 16 +/- 10 months, with EV71-related hemodynamically unstable CPF, which was refractory to conventional treatments, who were rescued by transsternal ECLS from 2000 to 2008. The clinical manifestations and outcomes of the 13 children (present cohort) were compared with those of 10 children (past cohort) who had EV71-related CPF without ECLS between 1998 and 2000.

RESULTS

Among these 13 patients, 10 were successfully weaned off ECLS and survived. The myocardial recovery time was 71 +/- 28 (median, 69) h, and the ECLS duration was 93 +/- 33 (median, 93) h. Six surviving patients had a good neurological outcome at hospital discharge. All surviving patients had some neurological sequelae but showed improvement at follow-up, including dysphagia in nine, central hypoventilation in seven, limb weakness in six and seizure in three. The present cohort had better neurological outcomes (46 vs. 0%, P = 0.005) and a higher survival rate (77 vs. 30%, P = 0.024) than the past cohort, respectively.

CONCLUSIONS

Patients with EV71-related CPF supported by ECLS had a higher survival rate and fewer neurological sequelae than those who only received conventional treatments. ECLS is an effective alternative method for treatment of children with refractory EV71-related CPF.

Pediatric cardiac transplantation: management issues

Pediatric heart transplantation is an effective therapeutic modality for children with end-stage heart disease. The overall survival of young heart recipients is very good: 89% to 92% one year survival. Survival data for the long term indicates that pediatric heart recipients have a very good chance of living for decades. Advances in immunosuppression have lent optimism for the future. There are now alternatives in induction, maintenance, and acute rejection therapy. Immunosuppressants are more specific in action and prevent and treat allograft rejection with less toxic side effects and decreased morbidity. Acute rejection and infection are early complications that reduce in incidence significantly after six months post-transplant. Graft coronary artery disease continues to be the most significant hurdle to long-term survival. Currently there is a plateau in the number of heart transplants performed annually. Lack of available pediatric donors plays a large role in the paucity of pediatric transplants. This review focuses on the key management issues involved in the care of the pediatric heart transplant recipient and incorporates the experiences and protocols of the Stanford University Pediatric Heart Transplant Program.