No abstract

OBJECTIVES:Children presenting with acute myocarditis may experience rapid clinical deterioration requiring extracorporeal membrane oxygenation (ECMO); however, our understanding of best practices and timing of ECMO initiation are lacking. We explored the relationships between pre-cannulation factors and survival in this high-acuity patient population. DESIGN:Retrospective review of a large international registry. Primary outcome was survival to hospital discharge, stratified by incident cardiac arrest (CA) prior to ECMO and time to cannulation after intubation. SETTING AND SUBJECTS:The Extracorporeal Life Support Organization registry was queried for patients less than or equal to 18 years old receiving ECMO support for myocarditis between 2007 and 2018. Exclusion criteria included being nonindex runs, non-venoarterial ECMO or missing data points for main variables studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:Population characteristics and survival were compared using t test, Wilcoxon rank-sum test, or Fisher exact test. Multivariable logistic regression was used for significant factors in the unadjusted logistic regression. Among 506 index ECMO runs in pediatric patients with myocarditis, survival for the cohort was 72%, with no difference between early and late eras (2007-2012 vs 2013-2018; p = 0.69). Survivors demonstrated higher pre-ECMO pH levels as well as shorter intubation-to-cannulation (ITC) times (3 hr [interquartile range (IQR)], 1-14 hr vs 6 hr [IQR, 2-20 hr]; p = 0.021). CA occurred within 24 hours prior to ECMO cannulation, including extracorporeal cardiopulmonary resuscitation, in 54% of ECMO runs (n = 273). Accounting for the interaction between pre-ECMO CA occurrence and ITC time, longer ITC time remained associated with lower survival for patients who did not experience a CA prior to ECMO, with adjusted odds ratio of 0.09 (IQR, 0.02-0.40; p = 0.002) for ITC time greater than or equal to 18 hours. CONCLUSIONS:The results of this multicenter analysis of ECMO utilization and outcomes for pediatric myocarditis suggest that patients approaching ECMO cannulation who have not experienced CA may have better survival outcomes if cannulated onto ECMO early after intubation.

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Introduction: Acute myocarditis causing cardiogenic shock commonly requires mechanical circulatory support. While it has been shown to be associated with survival to discharge in reports comparing indications for ECMO, our understanding of the impact of patient care related factors on outcomes remains limited by single center analyses and lack of consensus on diagnostic criteria. We therefore aimed to describe ECMO utilization and outcomes for pediatric patients requiring ECMO for acute myocarditis by sampling contemporary cohorts from the Extracorporeal Life Support Organization registry. Methods: Data was requested from ELSO database to include all pediatric patients under 19 years of age with a diagnosis of acute myocarditis who received ECMO support between 2007 and 2018. Index cases were utilized while non-VA ECMO runs were excluded. Primary outcome was mortality. Characteristics of the population are compared by mortality using t-test, Wilcoxon rank sum test, or Fisher’s exact test. Univariate analysis was performed. Multivariate logistic regression was used for significant factors in the unadjusted logistic regression. Results: We analyzed 924 ECMO runs after applying exclusion criteria. Overall survival for the cohort was 69%. Patients experiencing cardiac arrest requiring ECMO (ECPR) were less likely to survive compared to non-ECPR patients (61% vs 72%, p<0.01). The time from intubation from ECMO was found to be associated with mortality, with increased time from intubation to ECMO cannulation in survivors of 6hrs [IQR 2-22] vs non-survivors 9.5hrs [IQR 2-33], p<0.01). Conclusions: The results of this multicenter analysis of ECMO utilization and outcomes for pediatric myocarditis reveal a lower likelihood of survival when the indication for ECMO cannulation is ECPR. Increased time from intubation to ECMO cannulation may impact outcomes as much as markers of inadequate oxygen delivery. This suggests that earlier ECMO cannulation may improve outcomes for pediatric patients presenting with acute myocarditis. Further investigation into the factors distinguishing ECPR from non-ECPR patients with myocarditis are needed.