35. EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) FOR POSTCARDIOTOMY FAILURE IN CHILDREN: SIGNIFICANCE OF SHUNT MANAGEMENT IN THE SINGLE VENTRICLE
James Jaggers*, Joseph Forbess, Jon Meliones, Paul M. Kirshbom, Coleen Miller, Ross M. Ungerleider*
Duke University Medical Center
Durham, North Carolina, USA
BACKGROUND
ECMO is valuable for the occasional patient that requires cardiac or pulmonary support after congenital heart repair. Infants with single ventricles and aortopulmonary shunts (APS) following palliation constitute a challenging group of ECMO patients. Although many centers advocate total or partial occlusion of the shunt during the period of ECMO, this can lead to lung ischemia and makes weaning from ECMO more difficult since the shunt must first be reopened.
METHODS AND RESULTS
We retrospectively reviewed 35 consecutive infants and children (age 1-820 days; median 15 days) out of 1,020 patients (3.4%) who required ECMO after repair of congenital cardiac lesions from February 1994 to April 1999. Twenty-five patients underwent two ventricle repairs and 10 patients. had single ventricle palliations (nine with APS; one with Glenn). Overall hospital survival was 21/35 (60%). There were four additional late deaths giving an overall long-term survival of 49%. Hospital survival was generally better for those patients in whom support was initiated in the OR (10/15; 67%) vs postoperative in the ICU (11/20; 55%).
Survival was also decreased when ECMO was initiated in response to cardiac arrest (3/6; 50%). For patients with APS, survival was significantly better (4/5; 80%) if the APS was left open during the period of support (with pump flows increased as necessary to adequately perfuse both the systemic and pulmonary bed) compared to those in whom the shunt was occluded (0/4; 0%) (P=0.047). Two APS patients. have gone on to Fontan, one to Glenn and one awaits Glenn. The one death was related to renal failure that was present prior to cardiac surgery.
CONCLUSION
The ability to readily implement ECMO support is vital to improving survival after surgery for complex congenital heart defects in infants and children. Patients with marginal cardiac performance may benefit from early institution of ECMO in the operating room (after weaning from CPB but before transfer to the ICU). ECMO for patients with single ventricle palliation can have excellent long-term success. In infants with single ventricles and APS, leaving the shunt open during the period of support can simplify ECMO and markedly improve outcome.
