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Association of Extracorporeal Membrane Oxygenation Support Adequacy and Residual Lesions With Outcomes in Neonates Supported After Cardiac Surgery*

Howard, Taylor S. MD; Kalish, Brian T. MD; Wigmore, Daniel BS; Nathan, Meena MD, FRCS; Kulik, Thomas J. MD; Kaza, Aditya K. MD; Williams, Kathryn MS; Thiagarajan, Ravi R. MBBS, MPH

doi: 10.1097/PCC.0000000000000943
Cardiac Intensive Care

Objectives: There is a paucity of data regarding the impact of extracorporeal membrane oxygenation support, adequacy of surgical repair, and timing of intervention for residual structural lesions in neonates cannulated to extracorporeal membrane oxygenation after cardiac surgery. Our goal was to determine how these factors were associated with survival.

Design: Retrospective study.

Setting: Cardiovascular ICU.

Subjects: Neonates (≤ 28 d old) with congenital heart disease cannulated to extracorporeal membrane oxygenation after cardiac surgery during 2006–2013.

Interventions: None.

Measurements and Main Results: Eighty-four neonates were cannulated to venoarterial extracorporeal membrane oxygenation after cardiac surgery. Survival to discharge was 50%. There was no difference in survival based on surgical complexity and those with single or biventricular congenital heart disease. Prematurity (≤ 36 wk gestation; odds ratio, 2.33; p = 0.01), preextracorporeal membrane oxygenation pH less than or equal to 7.17 (odds ratio, 2.01; p = 0.04), need for inotrope support during extracorporeal membrane oxygenation (odds ratio, 3.99; p = 0.03), and extracorporeal membrane oxygenation duration greater than 168 hours (odds ratio, 2.04; p = 0.04) were all associated with increased mortality. Although preextracorporeal membrane oxygenation lactate was not significantly different between survivors and nonsurvivors, unresolved lactic acidosis greater than or equal to 72 hours after cannulation (odds ratio, 2.77; p = 0.002) was associated with increased mortality. Finally, many patients (n = 70; 83%) were noted to have residual lesions after cardiac surgery, and time to diagnosis or correction of residual lesions was significantly shorter in survivors (1 vs 2 d; p = 0.02).

Conclusions: Our data suggest that clearance of lactate is an important therapeutic target for patients cannulated to extracorporeal membrane oxygenation. In addition, timely identification of residual lesions and expedient interventions on those lesions may improve survival.

Supplemental Digital Content is available in the text.

1Departments of Medicine and Pediatrics, Children’s Hospital Boston, Harvard Medical School, Boston, MA.

2Department of Cardiology, Children’s Hospital Boston, Harvard Medical School, Boston, MA.

3Departments of Cardiothoracic Surgery and Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, MA.

*See also p. 1093.

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Dr. Nathan disclosed he is supported by a K23 grant and Co-Chair of project supported by the Pediatric Heart Network for work not related to this publication. Dr. Kulik received funding from malpractice insurance company and from meeting organizers. Dr. Thiagarajan received financial support for serving as a member of an Events Adjudication Committee for Bristol Myers Squibb. His institution received funding from Bristol Myers Squibb. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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©2016The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies