Early outcomes of moderate-to-high-risk pediatric congenital cardiac surgery and predictors of extracorporeal circulatory life support requirement

Mimi Xiaoming Deng; Christoph Haller; Kasey Moss; Sudipta Saha; Kyle Runeckles; Chun-Po Steve Fan; Bhavikkumar Langanecha; Alejandro Floh; Anne-Marie Guerguerian; Osami Honjo

doi:10.3389/fped.2024.1282275

Early outcomes of moderate-to-high-risk pediatric congenital cardiac surgery and predictors of extracorporeal circulatory life support requirement

Front Pediatr. 2024 Mar 8:12:1282275. doi: 10.3389/fped.2024.1282275. eCollection 2024.

Authors

Mimi Xiaoming Deng^#¹, Christoph Haller^#^{1

2}, Kasey Moss^{1

3}, Sudipta Saha⁴, Kyle Runeckles⁴, Chun-Po Steve Fan⁴, Bhavikkumar Langanecha⁵, Alejandro Floh⁵, Anne-Marie Guerguerian⁵, Osami Honjo^{1

2}

Affiliations

¹ Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada.
² Department of Surgery, University of Toronto, Toronto, ON, Canada.
³ Faculty of Internal Medicine, McMaster University, Hamilton, ON, Canada.
⁴ Rogers Computational Program, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
⁵ Department of Critical Care Medicine, Labatt Family Heart Centre, Toronto, ON, Canada.

^# Contributed equally.

Abstract

Background: Cardiopulmonary failure refractory to medical management after moderate-to-high-risk congenital cardiac surgery may necessitate mechanical support with veno-arterial extracorporeal membrane oxygenation (ECMO). On the extreme, ECMO can also be initiated in the setting of cardiac arrest (extracorporeal cardiopulmonary resuscitation, ECPR) unresponsive to conventional resuscitative measures.

Methods: This was a single-center retrospective cohort study of patients (n = 510) aged <3 years old who underwent cardiac surgery with cardiopulmonary bypass with a RACHS-1 score ≥3 between 2011 and 2014. Perioperative factors were reviewed to identify predictors of ECMO initiation and mortality in the operating room (OR) and the intensive care unit (ICU).

Results: A total of 510 patients with a mean surgical age of 10.0 ± 13.4 months were included. Among them, 21 (4%) patients received postoperative ECMO-12 were initiated in the OR and 9 in the ICU. ECMO cannulation was associated with cardiopulmonary bypass duration, aortopulmonary shunt, residual severe mitral regurgitation, vaso-inotropic score, and postprocedural lactate (p < 0.001). Of the 32 (6%) total deaths, 7 (22%) were ECMO patients-4 were elective OR cannulations and 3 were ICU ECPR. Prematurity [hazard ratio (HR): 2.61, p < 0.01), Norwood or Damus-Kaye-Stansel procedure (HR: 4.29, p < 0.001), postoperative left ventricular dysfunction (HR: 5.10, p = 0.01), residual severe tricuspid regurgitation (HR: 6.06, p < 0.001), and postoperative ECMO (ECPR: HR: 15.42, p < 0.001 vs. elective: HR: 5.26, p = 0.01) were associated with mortality. The two patients who were electively cannulated in the ICU survived.

Discussion: Although uncommon, postoperative ECMO in children after congenital cardiac surgery is associated with high mortality, especially in cases of ECPR. Patients with long cardiopulmonary bypass time, residual cardiac lesions, or increased vaso-inotropic requirement are at higher risk of receiving ECMO. Pre-emptive or early ECMO initiation before deterioration into cardiac arrest may improve survival.

Keywords: cardiac; congenital; extracorporeal circulatory membrane oxygenation; heart; intensive care; surgery.

Grants and funding

The authors declare that no financial support was received for the research, authorship, and/or publication of this article.