Perioperative mechanical circulatory support in children: An analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

Abstract

Objectives Analyses of mechanical circulatory support (MCS) in pediatric heart surgery have primarily focused on single-center outcomes or narrow applications. We describe patterns of use, patient characteristics, and MCS-associated outcomes across a large multicenter cohort. Methods Patients (<18yrs) in the STS Congenital Heart Surgery Database (2000-2010) were included. Characteristics and outcomes of those receiving post-operative MCS were described, and Bayesian hierarchical models were used to examine variation in adjusted MCS rates across institutions. Results Of 96,596 operations (80 centers), MCS was used in 2.4%. MCS patients were younger (13d v. 195d, p<0.0001) and more often had STS-defined preoperative risk factors (57.2% v. 32.7%, p<0.0001). Operations with the highest MCS rates included the Norwood procedure (17%) and complex biventricular repairs (arterial switch/VSD/arch repair-14%). Over half of MCS patients (53.2%) did not survive to hospital discharge (vs. 2.9%, non-MCS patients, p<0.0001). MCS-associated mortality was highest for truncus arteriosus and Ross-Konno operations (both 71%). Hospital-level MCS rates adjusted for patient characteristics and case mix varied by 15-fold across institutions; both high and low volume hospitals had substantial variation in MCS rates. Conclusion Perioperative MCS use varies widely across centers. MCS rates are highest overall for the Norwood procedure and complex biventricular repairs. Although MCS can be a life-saving therapy, over half of MCS patients do not survive to hospital discharge with mortality >70% for some operations. Future studies aimed at better understanding appropriate indications, optimal timing, and management of MCS may help to reduce variation in MCS across hospitals and improve outcomes.

Long-Term Survival and Reintervention After the Ross Procedure Across the Pediatric Age Spectrum

“…The relatively high risk of death in this age group is not unexpected: most had left ventricular dysfunction preoperatively and were severely ill, with limited treatment options aside from a Ross operation, as nearly two-thirds had already undergone a prior intervention, predominately balloon valvuloplasty. Many of these infants required postoperative ECMO, as reported by others [16,20]. Older children and adolescents in our study had 15-year survival similar to that of young adults undergoing the Ross procedure in a recently published large series [10].…”

Association of Hospital-Level Volume of Extracorporeal Membrane Oxygenation Cases and Mortality. Analysis of the Extracorporeal Life Support Organization Registry

“…To date, there are no evidencebased protocols for patient selection or ECMO management. Without guiding evidence, there is variation in the case-mix (23,25,43), primary diagnosis (23,25,43), modes of cannulation (10), equipment used (44), and anticoagulation for patients receiving ECMO (45). Consequently, future research must focus on what enables one hospital to achieve better outcomes.…”

Use of Extracorporeal Membrane Oxygenation and Mortality in Pediatric Cardiac Surgery Patients With Genetic Conditions: A Multicenter Analysis*

“…Perioperative ECMO use among children with CHD is 2.7–3% of surgical cases (6–7). Assessment of perioperative risk of mortality or need for ECMO among children with GC and CHD is complex because the number of GC that have associated congenital heart malformation is large but the number of surgical patients with the same GC and cardiac diagnosis are small, with the exception of Trisomy 21 (T21).…”