Trends in the use of VV-ECMO for respiratory ECLS among neonates, pediatric, and adult patients are shown in Figure 5.
Neonatal and Pediatric Cardiac Extracorporeal Life Support
To date, 6,475 neonates have been supported with ECLS for cardiac indications with 42% surviving to hospital discharge (Table 1). The registry contained information on 8,374 pediatric patients undergoing cardiac ECLS with 51% surviving to hospital discharge. In 2015, neonatal and pediatric cardiac ECLS reported included 446 neonates, 319 infants (age: >30 days to <1 year), and 281 children (age: 1 to < 16 years) with survival to discharge of 45%, 55%, and 61%, respectively. Use and survival for this cohort was higher in the most recent time period and in older children (Figure 6, A and B).
Congenital heart disease (commonly for postoperative support after corrective or palliative cardiac surgery), cardiogenic shock, and cardiomyopathy were the most common diagnoses in this cohort (Table 9). Patients with myocarditis and cardiomyopathy had the highest survival. Venoarterial ECMO (97%) was the most commonly used mode of ECLS. There was wide variability in survival based on type of congenital heart disease. Children with left heart lesions had lower survival compared with those with right heart congenital disease. Extracorporeal membrane oxygenation duration was shorter in neonates and pediatric patients supported with ECLS for cardiac compared with respiratory indications. Patients with myocarditis had longer ECLS support duration compared with other indications and had the best survival.
Adult Cardiac Extracorporeal Life Support
The registry contains 9,025 adult (age >16 years) patients in the registry with 41% surviving to hospital discharge (Table 1). During 2015, 2,167 cases were reported to the registry with 42% surviving to hospital discharge. Cardiogenic shock was the most common diagnosis associated with ECLS use, with 42% surviving to hospital discharge (Table 9). Adults with congenital heart disease had the lowest survival (37%), and those with myocarditis had the best survival in this population. Similar to pediatric patients, average duration of ECMO was shorter compared with respiratory ECLS, and VA ECMO (98%) was used in the vast majority of patients. Figure 6C shows use and survival trends in adults supported with ECLS for cardiac indications.
Extracorporeal Life Support to Support Cardiopulmonary Resuscitation
The registry contained 4,332 pediatric and 2,885 adults supported with ECPR with survival to discharge of 41% in pediatric and 29% in the adult groups.
Adverse Events During Extracorporeal Life Support
Common adverse events encountered during the course of ECMO are shown in Table 10. Adverse events vary by age and indication for ECMO are shown in Table 10.
Extracorporeal life support is increasingly used worldwide to support patients with critical cardiopulmonary dysfunction refractory to conventional therapies. This report summarizes data collected by the ELSO data registry, and provides a summary of current global use and outcomes for ECLS. Since the last registry report in 2012, there has been an increase in ECLS volume and number of ECLS centers reporting to the registry, especially international centers, and the data contained in the registry provide an accurate representation of ECLS use and outcomes worldwide.9
Adults supported with ECLS for respiratory and cardiac failure are now the largest group of patients being reported to the registry. The increased adult ECLS volume may represent a true change in ECLS use in adults. Alternatively, the large adult ECLS volume recently reported may be related to an increase in the number adult ECLS centers currently reporting to ELSO. However, our impression is that since the novel H1N1 influenza epidemic, and the publication of the CESAR trial, there has been a significant growth in the use of ECLS in adults with respiratory failure.10,11 Use of ECLS for cardiogenic shock is the most common cardiac indication for ECLS use in adults. Extracorporeal life support has been used in this population to bridge patients in cardiogenic shock to coronary intervention procedures with good success.12 Extracorporeal life support for support of adult respiratory and cardiac failure is expected to grow in the future.
Extracorporeal life support remains an important support modality for critically ill children. As previously described, the use of ECLS for neonatal respiratory failure is decreasing.8 In addition, ECLS survival for neonatal respiratory failure has decreased. The reasons for the decline in survival are not clear; however, it is possible that with advances in mechanical ventilation and availability in inhaled nitric oxide, the risk profile of neonates with respiratory failure placed on ECLS represents a more critically ill population. Similar to adults, ECLS use for pediatric respiratory failure is increasing, and survival is excellent.13 Extracorporeal life support remains an important support modality for neonatal and pediatric patients with cardiac disease. In these patients, ECLS is commonly used to support cardiac failure after surgery for congenital heart disease. Survival in the population is strongly influenced by type of congenital heart disease and the complexity of the cardiac surgical procedure.14 Increased use of ECLS in neonates and children for cardiac indications may be expected to grow, given the increasing complexity of congenital heart surgery being performed in many centers.
Another important use of ECLS is to support failure to achieve spontaneous return of circulation during CPR (ECPR).15,16 In 2015, approximately 17% of all pediatric and 14% of all adult ECLS patients reported to the registry received ECPR. Poor outcomes for cardiac arrest resuscitated with conventional CPR, improved ECLS technology, improved mobility of ECLS equipment, and ability to deploy at ECLS at point of care have increased the use of ECPR. Survival without neurologic injury is related to the quality of CPR provided before ECLS.
Although life saving in many instances, adverse events during ECLS are common, often resulting in mortality or permanent injury. Adverse events vary by age, indication for ECMO, and mode of ECMO used (higher in VA-ECMO).17 Thus, successful ECLS requires appropriate patient selection, skilled ECMO management with trained providers, and health care infrastructure that can help prevent or manage adverse events and hence requires considerable resources and manpower and is expensive.18 Recent reports describing an association between center ECMO volume and survival highlight these issues19,20.
The ELSO registry has collected important information on ECLS use for centers worldwide and has helped understand ECLS use and outcomes. Variables collected in the registry have been recently revised to include pre-ECLS severity of illness, International Classification of Disease 10th Version (ICD-10) diagnosis and procedure codes, and newer adverse event variables. These changes will hopefully help enhance our understanding of severity of illness before ECLS and its influence on ECLS survival, as well as changing trends and challenges with ECLS use in the future. The ELSO registry remains an important and valuable source of ECLS information that will continue to influence the use of ECLS.
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Keywords:Copyright © 2017 by the American Society for Artificial Internal Organs
extracorporeal life support; Extracorporeal Life Support Organization Registry report; survival; adverse events