Extracorporeal Membrane Oxygenation for Bridge to Heart Transplantation Among Children in the United States

Abstract

Background-Extracorporeal membrane oxygenation (ECMO) has served for Ͼ2 decades as the standard of care for US children requiring mechanical support as a bridge to heart transplantation. Objective data on the safety and efficacy of ECMO for this indication are limited. We describe the outcomes of ECMO as a bridge to heart transplantation to serve as performance benchmarks for emerging miniaturized assist devices intended to replace ECMO. Methods and Results-Data from the Extracorporeal Life Support Organization Registry and the Organ ProcurementTransplant Network database were merged to identify children supported with ECMO and listed for heart transplantation from 1994 to 2009. Independent predictors of wait-list and posttransplantation in-hospital mortality were identified. Objective performance goals for ECMO were developed. Of 773 children, the median age was 6 months (interquartile range, 1 to 44 months); 28% had cardiomyopathy; and in 38%, a bridge to transplantation was intended at ECMO initiation. Overall, 45% of subjects reached transplantation, although one third of those transplanted died before discharge; overall survival to hospital discharge was 47%. Wait-list mortality was independently associated with congenital heart disease, cardiopulmonary resuscitation before ECMO, and renal dysfunction. Posttransplantation mortality was associated with congenital heart disease, renal dysfunction, ECMO duration of Ͼ14 days, and initial ECMO indication as a bridge to recovery. In the objective performance goal cohort (nϭ485), patients with cardiomyopathy had the highest survival to hospital discharge (63%), followed by patients with myocarditis (59%), 2-ventricle congenital heart disease (44%) and 1-ventricle congenital heart disease (33%). Conclusion-Although ECMO is effective for short-term circulatory support, it is not reliable for the long-term circulatory support necessary for children awaiting heart transplantation. Fewer than half of patients bridged with ECMO survive to hospital discharge. More effective modalities for chronic circulatory support in children are urgently needed. (Circulation. 2011;123:2975-2984.)

Berlin Heart EXCOR Pediatric Ventricular Assist Device for Bridge to Heart Transplantation in US Children

“…Further analysis of infant EXCOR outcomes is warranted. Although survival for EXCOR patients is clearly superior to survival after ECMO for children >5 kg, a survival advantage is more difficult to demonstrate in children <5 kg on the basis of the published ECMO experience, 3,18,19 although individual center experiences may vary.…”

“…The EXCOR is a pneumatically driven paracorporeal blood pump manufactured in 5 sizes (10,25,30,50, and 60 cm 3 ) and is capable of providing both left VAD and biventricular VAD (BIVAD) support. 5 The trial design, inclusion criteria, and end points have been reported previously.…”

“…Thus, for years, pediatric clinicians have resorted to using short-term devices like extracorporeal membrane oxygenation (ECMO) to bridge children to heart transplantation despite its dismal success rate. 3 …”

Almanac 2012: Congenital heart disease. The national society journals present selected research that has driven recent advances in clinical cardiology

“…22 An international database showed that extracorporeal membrane oxygenation does not appear to be a reliable long-term circulatory support for children awaiting heart transplantation. 23 Fortunately, other options of support exist, and Stiller et al 24 provide a useful overview of mechanical cardiovascular support in infants and children.…”

Almanac 2012: congenital heart disease. The journals present selected research that has driven recent advances in clinical cardiology

“…An international database showed that extracorporeal membrane oxygenation does not appear to be a reliable long-term circulatory support for children awaiting heart transplantation (23). Fortunately, other options of support exist, and Stiller et al (24) provide a useful overview of mechanical cardiovascular support in infants and children.…”