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Cardiac extracorporeal life support: state of the art in 2007

Published online by Cambridge University Press:  26 November 2007

David S. Cooper*
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
Jeffrey P. Jacobs
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
Lisa Moore
Affiliation:
Advance Medical Therapies Coordinator, All Children’s Hospital, Saint Petersburg, Florida, United States of America
Arabela Stock
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
J. William Gaynor
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
Thomas Chancy
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
Michael Parpard
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
Dee Ann Griffin
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
Tami Owens
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
Paul A. Checchia
Affiliation:
St. Louis Children’s Hospital, Washington University School of Medicine, Missouri, United States of America
Ravi R. Thiagarajan
Affiliation:
Children’s Hospital Boston, Harvard Medical School, Massachusetts, United States of America
Thomas L. Spray
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
Chitra Ravishankar
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
*
Correspondence to: David S. Cooper, MD, MPH, The Congenital Heart Institute of Florida (CHIF), Clinical Assistant Professor of Pediatrics, University of South Florida, Florida Pediatric Associates, 880 Sixth Street South, Suite 370, St. Petersburg, FL 33701, USA. Tel: +727 767 4375; E-mail: davidscooper@verizon.net

Abstract

Mechanical circulatory support is an invaluable tool in the care of children with severe refractory cardiac and or pulmonary failure. Two forms of mechanical circulatory support are currently available to neonates, infants, and smaller children, namely extracorporeal membrane oxygenation and use of a ventricular assist device, with each technique having unique advantages and disadvantages. The intra-aortic balloon pump is a third form of mechanical support that has been successfully used in larger children, adolescents, and adults, but has limited applicability in smaller children. In this review, we discuss the current experiences with extracorporeal membrane oxygenation and ventricular assist devices in children with cardiac disease.

A variety of forms of mechanical circulatory support are available for children with cardiopulmonary dysfunction refractory to conventional management. These devices require extensive resources, both human and economic. Extracorporeal membrane oxygenation can be effectively used in a variety of settings to provide support to critically-ill patients with cardiac disease. Careful selection of patients and timing of intervention remains challenging. Special consideration should be given to children with cardiac disease with regard to anatomy, physiology, cannulation, and circuit management. Even though exciting progress is being made in the development of ventricular assist devices for long-term mechanical support in children, extracorporeal membrane oxygenation remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation.

As the familiarity and experience with extracorporeal membrane oxygenation has grown, new indications have evolved, including emergent resuscitation. This utilization has been termed extracorporeal cardiopulmonary resuscitation. The literature supporting emergent cardiopulmonary support is mounting. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Due to the limitations of conventional circuits for extracorporeal membrane oxygenation, some centres have developed novel systems for rapid cardiopulmonary support.

Many centres previously considered a functionally univentricular circulation to be a contraindication to extracorporeal membrane oxygenation, but improved results have been achieved recently with this complex subset of patients. The registry of the Extracorporeal Life Support Organization recently reported the outcome of extracorporeal life support used in neonates for cardiac indications from 1996 to 2000. Of the 740 neonates who were placed on extracorporeal life support for cardiac indications, 118 had hypoplastic left heart syndrome. There was no significant difference in survival between these patients and those with other defects. It is now common to use extracorporeal membrane oxygenation to support patients with a functionally univentricular circulation, and reasonable survival rates are to be expected.

Although extracorporeal membrane oxygenation has become a standard of care for many paediatric centres, its use is limited to those patients who require only short-term cardiopulmonary support. Mechanical ventricular assist devices have become standard therapy for adults with cardiac failure refractory to maximal medical management. Several devices are readily available in the United States of America for adults, but there are fewer options available to children. Over the last few years, substantial progress has been made in paediatric mechanical support. Ventricular assist devices are being used with increasing frequency in children with cardiac failure refractory to medical therapy for primary treatment as a long-term bridge to recovery or transplantation. The paracorporeal, pneumatic, pulsatile “Berlin Heart” ventricular assist device is being used with increasing frequency in Europe and North America to provide univentricular and biventricular support. With this device, a patient can be maintained on mechanical circulatory support while extubated, being mobilized, and feeding by mouth.

Mechanical circulatory support should be anticipated, and every attempt must be made to initiate support “urgently” rather than “emergently”, before the presence of dysfunction of end organs or circulatory collapse. In an emergency, these patients can be resuscitated with extracorporeal membrane oxygenation and subsequently transitioned to a long-term ventricular assist device after a period of stability.

Type
Original Article
Copyright
Copyright © Cambridge University Press 2007

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References

1. Jacobs, JP. Pediatric mechanical circulatory support. In: Mavroudis C, Backer CL (eds). Pediatric Cardiac Surgery, 3rd edn. Mosby Inc., An affiliate of Elsevier, Philadelphia, Pennsylvania, 2003, pp 778792.Google ScholarPubMed
2. Duncan, BW. Pediatric mechanical circulatory Support. ASAIO J 2005; 51: ixxiv.CrossRefGoogle ScholarPubMed
3. The January 2007 Extracorporeal Life Support Organization (ELSO) Extracorporeal Life Support (ECLS) Registry Report International Summary. Ann Arbor, Michigan, Extracorporeal Life Support Organization, 2007.Google Scholar
4. Koenig, PR, Ralston, MA, Kimball, TR, Meyer, RA, Daniels, SR, Schwartz, DC. Balloon atrial septostomy for left ventricular decompression in patients receiving extracorporeal membrane oxygenation for myocardial failure. J Pediatr 1993; 122: S95S99.CrossRefGoogle ScholarPubMed
5. Aiyagari, R, Rocchini, A, Remenapp, R, Graziano, JN. Decompression of the left atrium during extracorporeal membrane oxygenation using transseptal cannula incorporated into the circuit. Crit Care Med 2006; 34: 26032606.CrossRefGoogle ScholarPubMed
6. Chang, AC, Wernovsky, G, Kulik, T, Jonas, RA, Wessel, DL. Management of the neonate with transposition of the great arteries and persistent pulmonary hypertension. Am J Cardiol 1991; 68: 12531255.CrossRefGoogle ScholarPubMed
7. Luciani, GB, Chang, AC, Starnes, VA. Surgical repair of transposition of great arteries in neonates with persistent pulmonary hypertension. Ann Thorac Surg 1996; 61: 800805.CrossRefGoogle ScholarPubMed
8. Di Russo, GB, Clark, BJ, Bridges, ND, del Nido, PJ, Wessel, DL, Laussen, PC. Prolonged extracorporeal membrane oxygenation as a bridge to cardiac transplantation. Ann Thorac Surg 2000; 69: 925927.CrossRefGoogle ScholarPubMed
9. Booth, KL, Roth, SJ, Perry, SB, et al. . Cardiac catheterization of patients supported by extracorporeal membrane oxygenation. J Am Coll Cardiol 2002; 40: 16811686.CrossRefGoogle ScholarPubMed
10. Alsoufi, B, Shen, I, Karamlou, T, et al. . Extracorporeal life support in neonates, infants and children after repair of congenital heart disease: modern era results in a single institution. Ann Thorac Surg 2005; 80: 1521.CrossRefGoogle Scholar
11. Hoskote, A, Bohn, D, Gruenwald, C, et al. . Extracorporeal life support after staged palliation of a functional single ventricle: Subsequent morbidity and survival. J Thorac Cardiovasc Surg 2006; 131: 11141121.CrossRefGoogle Scholar
12. Aharon, AS, Drinkwater, DC, Churchwell, KB, et al. . Extracorporeal membrane oxygenation in children after repair of congenital cardiac lesions. Ann Thorac Surg 2001; 72: 20952101.CrossRefGoogle ScholarPubMed
13. Kolovos, NS, Bratton, SL, Moler, FW, et al. . Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery. Ann Thorac Surg 2003; 76: 14351441; discussion 1441–1442.CrossRefGoogle ScholarPubMed
14. Duncan, BW, Hraska, V, Jonas, RA, et al. . Mechanical circulatory support in children with cardiac disease. J Thorac Cardiovasc Surg 1999; 117: 529542.CrossRefGoogle ScholarPubMed
15. Thourani, V, Kirshborm, P, Kanter, P, et al. . Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) in Pediatric Cardiac Support. Ann Thorac Surg 2006; 82: 138145.CrossRefGoogle Scholar
16. 3rdWalters, HL, Hakimi, M, Rice, MD, Lyons, JM, Whittlesey, GC, Klein, MD. Pediatric cardiac surgical ECMO: multivariate analysis of risk factors for hospital death. Ann Thorac Surg 1995; 60: 329336.CrossRefGoogle ScholarPubMed
17. Morris, M, Ittenback, R, Godinez, R, et al. . Risk factors for mortality in 137 pediatric cardiac intensive care unit patients managed with extracorporeal membrane oxygenation. Crit Care Med 2004; 32: 10611069.CrossRefGoogle ScholarPubMed
18. del Nido, PJ, Dalton, HJ, Thompson, AE, Siewers, RD. Extracorporeal membrane oxygenator rescue in children during cardiac arrest after cardiac surgery. Circulation 1992; 86: II300II304.Google ScholarPubMed
19. Posner, JC, Osterhoudt, KC, Mollen, CJ, Jacobstein, CR, Nicolson, SC, Gaynor, JW. Extracorporeal membrane oxygenation as a resuscitative measure in the pediatric emergency department. Pediatr Emerg Care 2000; 16: 413415.CrossRefGoogle ScholarPubMed
20. Dalton, HJ, Siewers, RD, Fuhrman, BP, et al. . Extracorporeal membrane oxygenation for cardiac rescue in children with severe myocardial dysfunction. Crit Care Med 1993; 21: 10201028.CrossRefGoogle ScholarPubMed
21. Duncan, BW, Ibrahim, AE, Hraska, V, et al. . Use of rapid-deployment extracorporeal membrane oxygenation for the resuscitation of pediatric patients with heart disease after cardiac arrest. J Thorac Cardiovasc Surg 1998; 116: 305311.CrossRefGoogle ScholarPubMed
22. Ojito, JW, McConaghey, T, Jacobs, JP, Burke, RP. Rapid pediatric cardiopulmonary support system. J Extra Corpor Technol 1997; 29: 9699.Google ScholarPubMed
23. Jacobs, JP, Ojito, JW, McConaghey, T, et al. . Rapid cardiopulmonary support for children with complex congenital heart disease. Ann Thorac Surg 2000; 70: 742749.CrossRefGoogle ScholarPubMed
24. Hannan, R, Ojito, J, Ybarra, M, O’Brien, MC, Rossi, AF, Burke, RP. Rapid cardiopulmonary support in children with heart disease: a nine year experience. Ann Thorac Surg 2006; 82: 16371642.CrossRefGoogle ScholarPubMed
25. Morris, M, Wernovsky, G, Nadkarni, V. Survival outcomes after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory in-hospital pediatric cardiac arrest. Pediatr Crit Care Med 2004; 5: 440446.CrossRefGoogle ScholarPubMed
26. Alsoufi B, Osman O, Al-Radi OO, et al. Survival outcomes following rescue extracorporeal cardiopulmonary resuscitation in pediatric patients with refractory cardiac arrest. J Thorac Cardiovasc Surg, accepted for publication, in press.Google Scholar
27. Allan, C, Thiagarajan, R, Armsby, L, del Nido, PJ, Laussen, PC. Emergent use of extracorporeal membrane oxygenation during pediatric cardiac catheterization. Pediatr Crit Care Med 2006; 7: 212219.CrossRefGoogle ScholarPubMed
28. Duncan, B, Bohn, D, Atz, A, French, JW, Laussen, PC, Wessel, DL. Mechanical circulatory support for the treatment of children with acute fulminant myocarditis. J Thorac Cardiovasc Surg 2001; 122: 440448.CrossRefGoogle ScholarPubMed
29. Chen, Y, Yu, H, Huang, S, et al. . Experience and result of extracorporeal membrane oxygenation in treating fulminant myocarditis with shock: what mechanical support should be considered first? J Heart Lung Transplant 2005; 24: 8187.CrossRefGoogle ScholarPubMed
30. Asaumi, Y, Yasuda, S, Morii, I, et al. . Favourable clinical outcome in patients with cardiogenic shock due to fulminant myocarditis supported by percutaneous extracorporeal membrane oxygenation. Eur Heart J 2005; 26: 21852192.CrossRefGoogle ScholarPubMed
31. del Nido, PJ, Armitage, JM, Fricker, FJ, et al. . Extracorporeal membrane oxygenation support as a bridge to pediatric heart transplantation. Circulation 1994; 90: II66II69.Google ScholarPubMed
32. Fiser, W, Yetman, A, Gunselman, R, et al. . Pediatric arteriovenous extracorporeal membrane oxygenation (ECMO) as a bridge to cardiac transplantation. J Heart Lung Transplant 2003; 22: 770777.CrossRefGoogle Scholar
33. Gajarski, R, Mosca, R, Ohye, R, et al. . Use of extracorporeal life support as a bridge to pediatric cardiac transplantation. J Heart Lung Transplant 2003; 22: 2834.CrossRefGoogle ScholarPubMed
34. Kirshbom, PM, Bridges, ND, Myung, RJ, Gaynor, JW, Clark, BJ, Spray, TL. Use of extracorporeal membrane oxygenation in pediatric thoracic organ transplantation. J Thorac Cardiovasc Surg 2002; 123: 130136.CrossRefGoogle ScholarPubMed
35. Hoffman, TM, Spray, TL, Gaynor, JW, Clark, BJ 3rd, Bridges, ND. Survival after acute graft failure in pediatric thoracic organ transplant recipients. Pediatr Transplant 2000; 4: 112117.CrossRefGoogle ScholarPubMed
36. Galantowicz, ME, Stolar, CJ. Extracorporeal membrane oxygenation for perioperative support in pediatric heart transplantation. J Thorac Cardiovasc Surg 1991; 102: 148151.Google ScholarPubMed
37. Dhillon, R, Pearson, GA, Firmin, RK, Chan, KC, Leanage, R. Extracorporeal membrane oxygenation and the treatment of critical pulmonary hypertension in congenital heart disease. Eur J Cardiothorac Surg 1995; 9: 553556.CrossRefGoogle ScholarPubMed
38. Walker, GM, McLeod, K, Brown, KL, Franklin, O, Goldman, AP, Davis, C. Extracorporeal life support as a treatment of supraventricular tachycardia in infants. Pediatr Crit Care Med 2003; 4: 5254.CrossRefGoogle ScholarPubMed
39. Cohen, MI, Gaynor, JW, Ramesh, V, et al. . Extracorporeal membrane oxygenation for patients with refractory ventricular arrhythmias. J Thorac Cardiovasc Surg 1999; 118: 961963.CrossRefGoogle ScholarPubMed
40. Pastuszko, P, Gruber, PJ, Wernovsky, G, et al. . Thoratec left ventricular assist device as a bridge to recovery in a child weighing 27 kilograms. J Thorac Cardiovasc Surg 2004; 127: 12031204.CrossRefGoogle Scholar
41. Imamura, M, Schmitz, ML, Watkins, B, et al. . Venovenous extracorporeal membrane oxygenation for cyanotic congenital heart disease. Ann Thorac Surg 2004; 78: 17231727.CrossRefGoogle ScholarPubMed
42. Goldman, AP, Macrae, DJ, Tasker, RC, et al. . Extracorporeal membrane oxygenation as a bridge to definitive tracheal surgery in children. J Pediatr 1996; 128: 386388.CrossRefGoogle ScholarPubMed
43. Pizarro, C, Davis, DA, Healy, RA, Kerins, PJ, Norwood, WI. Is there a role for extracorporeal life support after stage I Norwood? Eur J Cardiothorac Surg 2001; 19: 294301.CrossRefGoogle Scholar
44. Jaggers, J, Forbess, J, Shah, A, et al. . Extracorporeal membrane oxygenation for infant postcardiotomy support: significance of shunt management. Ann Thorac Surg 2000; 69: 14761483.CrossRefGoogle ScholarPubMed
45. Hintz, S, Benitz, W, Colby, C, et al. . Utilization and outcomes of neonatal cardiac extracorporeal life support: 1996–2000. Pediatr Crit Care Med 2005; 6: 3338.CrossRefGoogle ScholarPubMed
46. Allan, C, Thiagarajan, R, del Nido, PJ, Roth, SJ, Almodovar, MC, Laussen, PC. Indication for initiation of mechanical circulatory support impacts survival of infants with shunted single-ventricle circulation supported with extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 2007; 133: 660667.CrossRefGoogle ScholarPubMed
47. Ravishankar, C, Dominguez, T, Kreutzer, J, et al. . Extracorporeal membrane oxygenation after stage I reconstruction for hypoplastic left heart syndrome. Pediatr Crit Care Med 2006; 7: 319323.CrossRefGoogle Scholar
48. Ungerleider, RM, Shen, I, Yeh, T, et al. . Routine mechanical ventricular assist following the Norwood procedure – improved neurologic outcome and hospital survival. Ann Thorac Surg 2004; 77: 1822.CrossRefGoogle ScholarPubMed
49. Klein, MD, Shaheen, KW, Whittlesey, GC, Pinsky, WW, Arciniegas, E. Extracorporeal membrane oxygenation for the circulatory support of children after repair of congenital heart disease. J Thorac Cardiovasc Surg 1990; 100: 498505.Google ScholarPubMed
50. Booth, K, Roth, S, Thiagarajan, R, Almodovar, MC, del Nido, PJ, Laussen, PC. Extracorporeal membrane oxygenation support of the Fontan and bidirectional Glenn circulations. Ann Thorac Surg 2004; 77: 13411348.CrossRefGoogle ScholarPubMed
51. Hamrick, S, Gremmels, D, Keet, C, et al. . Neurodevelopmental outcome of infant supported with extracorporeal membrane oxygenation after cardiac surgery. Pediatrics 2003; 111: 671675.CrossRefGoogle ScholarPubMed
52. Ibrahim, AE, Duncan, BW, Blume, ED, Jonas, RA. Long-term follow-up of pediatric cardiac patients requiring mechanical circulatory support. Ann Thorac Surg 2000; 69: 186192.CrossRefGoogle ScholarPubMed
53. Duncan, BW. Pediatric mechanical circulatory support in the United States: past, present, and future. ASAIO J 2006; 52: 525529.Google ScholarPubMed
54. Blume, ED, Naftel, DC, Bastardi, HJ, et al. . Outcomes of children bridged to heart transplantation with ventricular assist devices: a multi-institutional study. Circulation 2006; 113: 23132319.CrossRefGoogle ScholarPubMed
55. Hetzer, R, Potapov, EV, Stiller, B, et al. . Improvement in survival after mechanical circulatory support with pneumatic pulsatile ventricular assist devices in pediatric patients. Ann Thorac Surg 2006; 82: 917924discussion 924–925.CrossRefGoogle ScholarPubMed
56. Arabia, FA, Tsau, PH, Smith, RG, et al. . Pediatric bridge to heart transplantation: application of the Berlin Heart, Medos and Thoratec ventricular assist devices. J Heart Lung Transplant 2006; 25: 1621.CrossRefGoogle ScholarPubMed
57. Schmid, C, Debus, V, Gogarten, W, et al. . Pediatric assist with the Medos and Excor systems in small children. ASAIO J 2006; 52: 505508.Google ScholarPubMed
58. Kaczmarek, I, Sachweh, J, Groetzner, J, et al. . Mechanical circulatory support in pediatric patients with the MEDOS assist device. ASAIO J 2005; 51: 498500.CrossRefGoogle ScholarPubMed
59. Reinhartz, O, Stiller, B, Eilers, R, Farrar, DJ. Current clinical status of pulsatile pediatric circulatory support. ASAIO J 2002; 48: 455459.CrossRefGoogle ScholarPubMed
60. Sharma, MS, Webber, SA, Morell, VO, et al. . Ventricular assist device support in children and adolescents as a bridge to heart transplantation. Ann Thorac Surg 2006; 82: 926933.CrossRefGoogle ScholarPubMed
61. JrFraser, CD, Carberry, KE, Owens, WR, et al. . Preliminary experience with the MicroMed DeBakey pediatric ventricular assist device. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2006; 9: 109114.CrossRefGoogle Scholar
62. Kilic, A, Nolan, TD, Li, T, et al. . Early in vivo experience with the pediatric Jarvik 2000 heart. ASAIO J 2007; 53: 374378.CrossRefGoogle Scholar
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