Extracorporeal Membrane Oxygenation After Norwood Surgery in Patients With Hypoplastic Left Heart Syndrome: A Retrospective Single-Center Cohort Study From Brazil.

Rodrigo Freire Bezerra,Rodrigo Moreira Castro,Luciana Da Fonseca Da Silva,Rosangela Fitaroni,José Pedro Da Silva,Denilson Vieira Da Cruz,Victor Hugo Volpatto,Juliana Torres Pacheco,Sônia Meiken Franchi

doi:10.3389/fped.2022.813528

Abstract

BackgroundExtracorporeal membrane oxygenation (ECMO) is increasingly being used to support patients after the repair of congenital heart disease.ObjectiveWe report our experience with patients with a single functional ventricle who were supported by ECMO after the Norwood procedure, reviewing the outcomes and identifying risk factors for mortality in these patients.MethodsIn this single-center retrospective cohort study, we enrolled 33 patients with hypoplastic left heart syndrome (HLHS) who received ECMO support after the Norwood procedure between January 2015 and December 2019. The independent variables evaluated in this study were demographic, anatomical, and those directly related to ECMO support (ECMO indication, local of initiation, time under support, and urinary output while on ECMO). The dependent variable was survival. A p < 0.05 was considered statistically significant.ResultsThe ECMO support was applied in 33 patients in a group of 120 patients submitted to Norwood procedure (28%). Aortic atresia was present in 72.7% of patients and mitral atresia in 51.5%. For 15% of patients, ECMO was initiated in the operating room; for all other patients, ECMO was initiated in the intensive care unit. The indications for ECMO in the cardiac intensive care unit were cardiac arrest in 22 (79%) of patients, low cardiac output state in 10 (18%), and arrhythmia in 1 patient (3%). The median time under support was 5 (2–25) days. The median follow-up time was 59 (4–150) days. Global survival to Norwood procedure was 90.9% during the 30-day follow-up, being 33.3% for those submitted to ECMO. Longer ECMO support (p = 0.004) was associated with a higher risk of death in the group submitted to ECMO.ConclusionsThe mortality of patients with HLHS who received ECMO support after stage 1 palliation was high. Patients with low urine output were related to worse survival rates, and longer periods under ECMO support (more than 9 days of ECMO) were associated with 100% mortality. Earlier ECMO initiation before multiorgan damage may improve results.

Highlights

Extracorporeal membrane oxygenation (ECMO) is being used to provide mechanical circulatory support for patients with congenital or acquired heart disease in cardiac failure when conventional medical management has failed
The most common surgical strategy used as palliative therapy for hypoplastic left heart syndrome (HLHS) is the Norwood procedure, which has been used by our group for more than 35 years
We reviewed the outcomes of ECMO support and identified risk factors for mortality in these patients

Summary

Introduction

Extracorporeal membrane oxygenation (ECMO) is being used to provide mechanical circulatory support for patients with congenital or acquired heart disease in cardiac failure when conventional medical management has failed. ECMO has been used with increasing frequency to support pediatric patients after repair or palliation of congenital heart disease [1–4]. The introduction of the right ventricle-to-pulmonary artery conduit strategy [6] had helped to improve our results even in an era when ECMO support was not available. 10–12% of the newborns undergoing the Norwood procedure require advanced circulatory support, and despite increasing the overall survival rate, ECMO use is associated with a high mortality rate in international publications [1–3, 5]. Despite the increasing use of ECMO in such patients, only 31% survive until hospital discharge [2]. Extracorporeal membrane oxygenation (ECMO) is increasingly being used to support patients after the repair of congenital heart disease

Methods

Results

Discussion

Conclusion