Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study*

Abstract

Objectives: To assess the variation in timing of left atrial decompression and its association with clinical outcomes in pediatric patients supported with venoarterial extracorporeal membrane oxygenation across a multicenter cohort. Design: Multicenter retrospective study. Setting: Eleven pediatric hospitals within the United States. Patients: Patients less than 18 years on venoarterial extracorporeal membrane oxygenation who underwent left atrial decompression from 2004 to 2016. Interventions: None. Measurements and Main Results: A total of 137 patients (median age, 4.7 yr) were included. Cardiomyopathy was the most common diagnosis (47%). Cardiac arrest (39%) and low cardiac output (50%) were the most common extracorporeal membrane oxygenation indications. Median time to left atrial decompression was 6.2 hours (interquartile range, 3.8–17.2 hr) with the optimal cut-point of greater than or equal to 18 hours for late decompression determined by receiver operating characteristic curve. In univariate analysis, late decompression was associated with longer extracorporeal membrane oxygenation duration (median 8.5 vs 5 d; p = 0.02). In multivariable analysis taking into account clinical confounder and center effects, late decompression remained significantly associated with prolonged extracorporeal membrane oxygenation duration (adjusted odds ratio, 4.4; p = 0.002). Late decompression was also associated with longer duration of mechanical ventilation (adjusted odds ratio, 4.8; p = 0.002). Timing of decompression was not associated with in-hospital survival (p = 0.36) or overall survival (p = 0.42) with median follow-up of 3.2 years. Conclusions: In this multicenter study of pediatric patients receiving venoarterial extracorporeal membrane oxygenation, late left atrial decompression (≥ 18 hr) was associated with longer duration of extracorporeal membrane oxygenation support and mechanical ventilation. Although no survival benefit was demonstrated, the known morbidities associated with prolonged extracorporeal membrane oxygenation use may justify a recommendation for early left atrial decompression.

Atrial septostomy in patients supported with venoarterial extracorporeal membrane oxygenation: Analysis of the IMPACT registry data

“…The relationship of timing of decompression and outcomes have been assessed in the past with some studies suggestion late decompression associated with longer ECMO run but no impact on mortality while others have found no relationship. 3,4 This registry does not allow assessment of this relationship or the precise clinical markers used to determine the timing or indication for septostomy.…”

“…There is however, no consensus with regards to the timing and threshold for such an intervention with very significant variability in center practice. 4 Similarly, the performance of septostomy and associated procedural risks are not well established but are being increasingly reported. 2,3,5–7…”

Extracorporeal Membrane Oxygenation in Congenital Heart Disease

“…Earlier time to decompression following ECMO cannulation is associated with a shorter duration of ECMO and ICU length of stay [43,44]. It is important to note that an increased odds of survival has not been shown in children with congenital heart disease; however, survival benefit has been shown in those with myocarditis or dilated cardiomyopathy [41,43,45]. This is likely multifactorial in nature and requires additional study in patients specific to congenital heart disease.…”

Aortic Root Thrombosis on ECMO—A Novel Management Strategy

“…These strategies include LA decompression via atrial septostomy or atrial drain placement, LV decompression via percutaneous LV assist devices such as the Impella (Abiomed), and/or reducing SVR with vasodilators. 2,3…”