Pediatric Extracorporeal Membrane Oxygenation Support as Treatment for Refractory Cardiogenic Shock

Purpose: Extracorporeal membrane oxygenation (ECMO) remains the most commonly used tool as mechanical circulatory support in children. We report our experience on pediatric veno-arterial (v-a) ECMO support as treatment of refractory cardiogenic shock (CS). Methods: Between October 2004 and August 2015, 54 consecutive pediat- ric patients (31 male; age: 3.5±5.1 years, range: 1-17 years; mean weight: 14.3±11.1 kg, range: 2.8-60.5 kg) were supported on Levitronix CentriMag (n=41) and RotaFlow (n=13) v-a ECMO, at our institution. Indications for support were: failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n=35) and early donor graft failure (n=4); primary CS on congenital heart defect (n=4); acute myocarditis (n=3); and CS on chronic heart failure (n=8). Results: A central setting was established in 43 (79.6%) patients while peripherally in 11 (20.4%). Overall mean support time was 11.9±9.7 days (range: 1-43 days). Thirty-one (57.4%) patients died on ECMO mostly due to multiple organ dysfunction and sepsis. Overall success rate, in terms of survival on ECMO (n=23), weaning from mechanical support (n=13, 24.1%), bridge to heart transplantation (n=7, 12.9%) and bridge to long-term Berlin Heart Excor ventricular assist device (n=3, 5.5%), was 42.6%. Only fourteen (25.9%) patients were discharged since significant myocardial dys- function persisted or pulmonary hypertensive events occurred after weaning from ECMO. Multivariate analysis identified cardio-pulmonary resuscita- tion before ECMO, congenital heart defect, post-cardiotomy CS, and time on mechanical support as significant (p<0.001) predictors of mortality on ECMO. After adjusting per cohort of patients, univentricular physiology resulted to be a factor significantly (p<0.001) associated with an increased risk of mortality. Conclusion: Based on our preliminary results, ECMO has the advantage of being cost-effective and rapidly applicable over a wide range of ages, weights thus providing biventricular cardiovascular and pulmonary support. Overall mortality during circulatory support remains high but probably an early ECMO installation could be beneficial to improve outcomes particularly after surgical repair. Single ventricle palliations with shunt-dependent pulmonary blood flow need to be accurately monitored and managed while on ECMO.