Post-cardiotomy Rescue Extracorporeal Cardiopulmonary Resuscitation in Neonates with Single Ventricle After Intractable Cardiac Arrest: Attrition After Hospital Discharge and Predictors of Outcome

Abstract

Extracorporeal cardiopulmonary resuscitation (ECPR) in children with cardiac arrest refractory to conventional cardiopulmonary resuscitation (CPR) has been reported with encouraging results. We reviewed outcomes of neonates with functional single ventricle (FSV) surviving post-cardiotomy ECPR after hospital discharge. Fifty-eight patients who required post-cardiotomy extracorporeal membrane oxygenation (ECMO) since the introduction of our ECPR protocol (January 2007-December 2011) were identified. Forty-one were neonates. Survival analysis was conducted. Of 41 neonates receiving post-cardiotomy ECMO, 32 had FSV. Twenty-one had ECPR. Fourteen underwent Norwood operation (NO) for hypoplastic left heart syndrome (HLHS). Seven had non-HLHS FSV. Four (of 7) underwent modified NO/DKS with systemic-to-pulmonary shunt (SPS), 2 SPS only and 1 SPS with anomalous pulmonary venous connection repair. Mean age was 6.8 ± 2.1 days. ECMO median duration was 7 days [interquartile range (IQR: 4-18)]. Survival to ECMO discontinuation was 72% (15 of 21 patients) and at hospital discharge 62% (13 of 21 patients). The most common cause of late attrition was cardiac. At last follow-up (median: 22 months; IQR: 3-36), 47% of patients were alive. Duration of ECMO and failure of lactate clearance within 24 h from ECMO deployment determined late survival after hospital discharge (p < 0.05). Rescue post-cardiotomy ECMO support in neonates with FSV carries significant late attrition. ECMO duration and failure in lactate clearance after deployment are associated with unfavorable outcome. Emphasis on CPR quality, refinement of management directives early during ECMO and aggressive early identification of patients requiring heart transplantation might improve late survival.

Outcomes of paediatric cardiac patients after 30 minutes of cardiopulmonary resuscitation prior to extracorporeal support

“…Many prior studies of extracorporeal cardiopulmonary resuscitation include patients with wide ranges of duration of chest compressions prior to cannulation, some of them including patients receiving less than 10 minutes of cardiopulmonary resuscitation prior to placement on mechanical support. 2,6,11,12,[18][19][20][21][22][23][24][25][26][27][28][29][30] Our focus on those patients receiving prolonged cardiopulmonary resuscitation provides information about a more discrete and potentially higher risk population. We focused on patients with primary cardiac disease because prior studies demonstrated increased survival with extracorporeal cardiopulmonary resuscitation and conventional cardiopulmonary resuscitation compared to non-cardiac patients.…”

“…4,33 We compared our findings with previous literature that only focus on paediatric cardiac extracorporeal cardiopulmonary resuscitation or paediatric cardiac extracorporeal membrane oxygenation with subgroup analysis of extracorporeal cardiopulmonary resuscitation patients. 2,6,11,12,[18][19][20][21][22][23][24][25][26][27][28][29][30] The Supplementary Table provides a review of paediatric extracorporeal cardiopulmonary resuscitation studies in the cardiac ICU literature. Several factors may account for differing results between our study and previous ones.…”

“…11,18,20,22,24,25,29 Second, others relied on subgroup analysis of larger reviews of cardiac extracorporeal membrane oxygenation support 2,11,18,20,25,26 rather than our study, with its specific focus on cardiac extracorporeal cardiopulmonary resuscitation. Third, our cohort focused on prolonged extracorporeal cardiopulmonary resuscitation and as such had a longer median duration of cardiopulmonary resuscitation (56 minutes) compared to the previous cardiac extracorporeal cardiopulmonary resuscitation reports where median duration ranged from 16 to 47.5 minutes 2,6,11,12,[18][19][20][25][26][27][28][29] with only four studies reporting a prolonged median duration similar to our study. 21,24,26,30 This factor would be expected to portend worse survival to our patients as prolonged cardiopulmonary resuscitation duration has been noted to be a predictor of mortality in paediatric cardiac patients undergoing extracorporeal cardiopulmonary resuscitation.…”

“…Data on neurological outcomes of cardiac extracorporeal cardiopulmonary resuscitation survivors are limited and based on different diagnostic modalities. 1,2,6,12,22,23,25,29 A meta-analysis by Joffe et al described 9 paediatric extracorporeal cardiopulmonary resuscitation studies with a total of 287 survivors and a 22% prevalence of neurological disability. 1 Four of these studies exclusively evaluated cardiac extracorporeal cardiopulmonary resuscitation patients and reported variable neurological outcomes using different assessment tools: Morris et al and Allan et al demonstrated moderate clinical neurological deficits in 29 and 20% of patients, respectively, while Kane et al and Sivarajan et al described Pediatric Cerebral Performance Categories scores of 3-4 in 21 and 67% of survivors, respectively.…”

Circulatory Flow Restoration Versus Cardiopulmonary Resuscitation: New Therapeutic Approach in Sudden Cardiac Arrest

“…The deployment of ECMO (ECPR), may improve outcomes of postoperative cardiac arrest in pediatrics (57). However, ECPR remains an invasive procedure, practiced with specialized teamwork available in few cardiac centers, which limits its applications to in-patient cardiac arrest (58). Besides, ECMO provides a steady-flow perfusion mode that promotes to endothelial dysfunction complications (50).…”