Extracorporeal Membrane Oxygenation in Children after Fontan Operation.

Abstract

To investigate outcomes of pediatric patients requiring extracorporeal membrane oxygenation (ECMO) after the Fontan operation. Retrospective cohort analysis of the Extracorporeal Life Support Organization (ELSO) registry including patients <18 years old who underwent ECMO after Fontan palliation between 2010-2023. Patients undergoing a first ECMO run during their Fontan surgical hospitalization were included. Among 281 children undergoing ECMO after Fontan palliation, survival to hospital discharge was 48.4%. Median age and weight were 3.9 years (IQR, 2.7-5.5) and 15 kg (IQR, 12-19). Veno-arterial ECMO was used in 92% of patients, multiple drainage cannulas in 21%, central cannulation in 49%, and Fontan pathway decompression in 51%. Survival did not differ according to use of multiple drainage cannulas or decompression strategy. Independent predictors of hospital mortality included pre-ECMO arrest (OR 1.88, p=0.042), pre-ECMO bicarbonate administration (OR 2.01, p=0.019), higher ECMO flow at 4 hours (OR 1.01, p=0.014), longer ECMO duration (OR 1.09, p=0.002), longer admission-to-cannulation time (OR 1.04, p=0.002), and neurologic (OR 5.99, p<0.001), renal (OR 2.92, p=0.005), or pulmonary complications (OR 13.07, p=0.022). Eight patients were transitioned to ventricular assist device support from ECMO and 6 underwent heart transplantation; survival in both groups was 50%. Hospital survival after ECMO following Fontan palliation has improved compared with prior reports. Avoidance of pre-ECMO arrest and earlier cannulation are potentially modifiable factors that may improve outcomes in these patients. Prospective studies are warranted to better define timing, outcomes and optimal support strategies in this population.