Stabilizing the Unstable: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database of Children Supported With Extracorporeal Membrane Oxygenation Before Cardiac Surgery.

Abstract

Children with heart disease and cardiopulmonary failure may be supported with extracorporeal membrane oxygenation (ECMO) for stabilization before cardiac surgery. This study describes their epidemiology and outcomes. The Society of Thoracic Surgeons Congenital Heart Surgery Database was queried for patients aged <18 years who underwent ECMO cannulation before and subsequently underwent their index surgery of that hospitalization from January 2016 to June 2021. Logistic regression for binary outcomes and competing risk analysis were used to identify factors associated with in-hospital mortality. Variables were selected by stepwise procedure using entry level P = .35. Those with P ≤ .1 were retained in the final model. Among 1215 patients who were identified, 294 (24%) were decannulated preoperatively, 339 (36.8%) were decannulated at the time of surgery, with 36 (10.6%) requiring recannulation. Of the 582 (63.2%) who remained on ECMO postoperatively, 541 (93%) were eventually decannulated. Intraoperative decannulation vs those who remained on ECMO was associated with significantly improved survival to hospital discharge (81.7% vs 67.8%, P < .001). The most common operations were heart transplant (n = 185 [15.2%]), systemic-pulmonary shunt placement (n = 111 [9.1%]), and Norwood (n = 77 [6.3%]). Multivariate analysis demonstrated younger age (odds ratio [OR], 0.90; 95% CI, 0.85-0.95; P < .001), longer cardiopulmonary bypass time (OR, 1.24; 95% CI, 1.12-1.38; P < .001), preoperative hepatic dysfunction (OR, 3.09; 95% CI, 1.74-5.50; P < .001), unplanned reoperation (OR, 1.93; 95% CI, 1.33-2.80; P < .001), and postoperative cardiac arrest (OR, 3.87; 95% CI, 2.65-5.66; P < .001) were associated with increased odds of in-hospital mortality, whereas decannulation before surgery was protective (OR, 0.41; 95% CI, 0.25-0.69; P < .001). ECMO before cardiac surgery can successfully stabilize children with failing circulations, with multiple factors that modulate outcomes. This analysis provides prognostic information to caregivers and families and may be used to inform clinical decision-making.