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Relationship Between Time to Left Atrial Decompression and Outcomes in Patients Receiving Venoarterial Extracorporeal Membrane Oxygenation Support: A Multicenter Pediatric Interventional Cardiology Early-Career Society Study*

Zampi, Jeffrey D. MD1; Alghanem, Fares1; Yu, Sunkyung MS1; Callahan, Ryan MD2; Curzon, Christopher L. DO3; Delaney, Jeffrey W. MD3; Gray, Robert G. MD4; Herbert, Carrie E. MD5; Leahy, Ryan A. MD, MS6; Lowery, Ray1; Pasquali, Sara K. MD, MHS1; Patel, Priti M. MD7; Porras, Diego MD2; Shahanavaz, Shabana MD8; Thiagarajan, Ravi R. MD, MPH2; Trucco, Sara M. MD9; Turner, Mariel E. MD10; Veeram Reddy, Surendranath R. MD11; West, Shawn C. MD9; Whiteside, Wendy MD12; Goldstein, Bryan H. MD12

Pediatric Critical Care Medicine: August 2019 - Volume 20 - Issue 8 - p 728-736
doi: 10.1097/PCC.0000000000001936
Cardiac Intensive Care

Objectives: To assess the variation in timing of left atrial decompression and its association with clinical outcomes in pediatric patients supported with venoarterial extracorporeal membrane oxygenation across a multicenter cohort.

Design: Multicenter retrospective study.

Setting: Eleven pediatric hospitals within the United States.

Patients: Patients less than 18 years on venoarterial extracorporeal membrane oxygenation who underwent left atrial decompression from 2004 to 2016.

Interventions: None.

Measurements and Main Results: A total of 137 patients (median age, 4.7 yr) were included. Cardiomyopathy was the most common diagnosis (47%). Cardiac arrest (39%) and low cardiac output (50%) were the most common extracorporeal membrane oxygenation indications. Median time to left atrial decompression was 6.2 hours (interquartile range, 3.8–17.2 hr) with the optimal cut-point of greater than or equal to 18 hours for late decompression determined by receiver operating characteristic curve. In univariate analysis, late decompression was associated with longer extracorporeal membrane oxygenation duration (median 8.5 vs 5 d; p = 0.02). In multivariable analysis taking into account clinical confounder and center effects, late decompression remained significantly associated with prolonged extracorporeal membrane oxygenation duration (adjusted odds ratio, 4.4; p = 0.002). Late decompression was also associated with longer duration of mechanical ventilation (adjusted odds ratio, 4.8; p = 0.002). Timing of decompression was not associated with in-hospital survival (p = 0.36) or overall survival (p = 0.42) with median follow-up of 3.2 years.

Conclusions: In this multicenter study of pediatric patients receiving venoarterial extracorporeal membrane oxygenation, late left atrial decompression (≥ 18 hr) was associated with longer duration of extracorporeal membrane oxygenation support and mechanical ventilation. Although no survival benefit was demonstrated, the known morbidities associated with prolonged extracorporeal membrane oxygenation use may justify a recommendation for early left atrial decompression.

1Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, MI.

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

3Division of Pediatric Cardiology, University of Nebraska Children’s Hospital, Omaha, NE.

4Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT.

5Division of Pediatric Cardiology, Johns Hopkins All Children’s Hospital, Saint Petersburg, FL.

6Department of Cardiology, Kosair Children’s Hospital, Louisville, KY.

7Division of Pediatric Cardiology, University of Illinois College of Medicine at Peoria, Peoria, IL.

8Division of Pediatric Cardiology, Washington University School of Medicine, St. Louis, MO.

9Division of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA.

10Division of Pediatric Cardiology, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York-Presbyterian, New York, NY.

11Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX.

12The Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH.

*See also p. 780.

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Supported, in part, by the CHAMPS for Mott Award, an institutional grant from the University of Michigan.

Dr. Zampi’s institution received funding from University of Michigan Department of Pediatrics (internal grant) and Siemens. Dr. Thiagarajan’s institution received funding from Bristol Myers Squibb and Pfizer. Dr. Goldstein received funding from St. Jude Medical, Medtronic, Edwards Lifesciences, and W.L. Gore & Associates. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies