Extracorporeal Membrane Oxygenation in Congenital Heart Disease

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.

Short‐Term Mortality Among Pediatric Patients With Heart Diseases Undergoing Veno‐Arterial Extracorporeal Membrane Oxygenation: A Systematic Review and Meta‐Analysis

“… 69 , 70 , 71 Both peripheral and central cannulation are commonly used approaches to cannulation for ECMO. 4 , 72 For peripheral cannulation, clinicians usually select internal jugular veins and carotid artery for cannulation. If the vessel size is adequate for a larger child, the femoral vein and artery can be used, which could cause possible ischemic damage to the leg.…”

Perioperative extracorporeal membrane oxygenation in pediatric congenital heart disease: Chinese expert consensus

“…When the pump flow is gradually reduced to less than 30% of the full flow for 6–24 hours, weaning can be attempted if the following conditions are met [ 10 , 68 – 70 ]: (1) with low levels of vasoactive drugs (epinephrine ≤ 0.02–0.05 μg/kg/minute, dopamine/dobutamine 3–5 μg/kg/minute), arterial pressure within the normal values and pulse pressure difference greater than 20 mmHg, CVP > 5 mmHg [ 10 ]; (2) left ventricular ejection fraction > 25%, left and right ventricular motion coordination and aortic valve velocity time integral ≥ 10 cm[ 69 ]; (3) with the ventilator parameters as follows: oxygen concentration ≤ 60%, tidal volume 6–8 mL/kg, peak inspiratory pressure < 30 cmH 2 O, PEEP 5–15 cmH 2 O and PaO 2 /FiO 2 > 200 mmHg after biventricular correction, PCO 2 ≤ 45 mmHg, pH > 7.3, SvO 2 ≥ 65%, blood lactate, electrolyte and hematocrit (HCT) values within the normal range; (4) in patients with a single ventricle, it is necessary to adjust the balance of systemic/pulmonary blood flow according to the cardiac surgical procedures and the level of peripheral blood oxygen saturation (SpO 2 ). The oxygenation index and mechanical ventilation parameters should meet the targets and all conditions remain stable.…”

“…Owing to the anatomical and physiological characteristics of CHD, low cardiac output, poor oxygenation and insufficient cerebral perfusion are prone to occur during chest compression. Therefore, when CPR fails to restore spontaneous circulation within 15 minutes, the ECPR procedure should be started immediately [ 70 , 77 ]. Timely application of ECPR can reduce organ damage and improve the survival of children with CHD in the hospital [ 78 – 81 ].…”

“…According to the anatomical characteristics of CHD and the speed of rescue, the ECPR cannulation strategy is formulated, central cannulation can be performed in the early stage within the postoperative 14 days, and cervical or femoral arteriovenous cannulation can be performed in children before surgery or during the late postoperative period [ 70 , 82 ].…”

Minimized Hemodiafiltration for Extracorporeal Membrane Oxygenation in Infants

“…The Society of Thoracic Surgeons reports that the frequency of the use of perioperative ECMO in cardiac surgery is 2.8%. 1 In conjunction with the underlying cardiac problem, decreased micturition up to acute renal failure may occur before or during treatment. Classic therapies are hemodialysis using a Shaldon catheter or peritoneal dialysis.…”