Extracorporeal Membrane Oxygenation Cannulation Timing in the Pediatric Myocarditis Population: An Exploratory Analysis From the Extracorporeal Life Support Organization Registry

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.

Case report: Foreign body aspiration requiring extracorporeal membrane oxygenation

“…Multiple etiologies could have contributed to the stroke: a thromboembolic process from ECMO, a rapid decrease in arterial CO 2 after cannulation that might have contributed to increased cerebrovascular constriction and decreased perfusion, a phenomenon described in adult ECMO patients (18), or myocardial stun with resultant change in cardiac ejection and change in brain perfusion. This phenomenon of myocardial stun could be due to different factors and in our patient can be related to increase in oxygen free radicals (19). Additional explanations could include severe prolonged hypoxemia and/or hypoperfusion, however, our patient did not suffer from episodes of severe hypoxia, lowest saturations were transient decreases into the mid 70%, and there were no hypotensive episodes recorded.…”

Contemporary Outcomes of Children With Acute Fulminant Myocarditis Supported With Peripheral Extracorporeal Membrane Oxygenation

“…Although earlier analysis of the ELSO registry noted 61% survival of a cohort from 1995 to 2006, 10 more recent analyses have demonstrated survival of approximately 72% in a cohort from 2007 to 2018. 11 Single-center reports on AFM have described survival rates of 64-93%, albeit many groups consisting of mixed populations, some of whom did not require ECMO. 3,4,[12][13][14][15][16] Our transplant-free survival in a cohort exclusively supported on ECMO was 75% despite the fact that 75% of our cohort received CPR before cannulation and 64% were receiving CPR during cannulation, previously identified risk factors for mortality.…”

Clinical Application of Extracorporeal Membrane Oxygenation in the Treatment of Fulminant Myocarditis

“…In patients with witnessed OHCA and those 70 years old with a shockable initial rhythm, initiation of ECMO should be considered as early as possible after 10–20 minutes of unsuccessful cardiopulmonary resuscitation [ 81 ]. A retrospective study conducted in Korea [ 82 ] emphasized that initiating VA-ECMO in CS patients with a vasoactive-inotropic score (VIS) of 32 yielded improved in-hospital outcomes, with no significant variance in the overall incidence of ECMO-related complications between low and high VIS groups, suggesting that the VIS score may be a marker for determining the initiation of hemodynamic support for VA-ECMO [ 83 ]. Identifying the optimal timing for ECMO initiation to enhance survival outcomes in FM patients remains an area of increased research.…”