Invited commentary

Abstract

Hannan and colleagues [1Hannan R.L. Ojito J.W. Ybarra M.A. O’Brien M.C. Rossi A.F. Burke R.P. Rapid cardiopulmonary support in children with heart disease: a nine-year experience.Ann Thorac Surg. 2006; 82: 1637-1642Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar] have collected an impressive group of patients with congenital heart disease requiring extracorporeal support for a 10-year period. During this time, their technique of extracorporeal support has evolved from standard extracorporeal membrane oxygenation (ECMO) to a rapid deployment cardiopulmonary support system (CPS). The CPS has the advantage of rapid set-up, low prime volumes, and portability. The authors have demonstrated an improvement in survivals between eras, coincident with the new system. However, due to the many systematic changes during the time period, it is difficult to define the factors resulting in the improved survival. The current article reports a 30-day survival of 55% for the entire cohort (57 of 103), with an improvement in survival from 45% prior to 1996 to 65% after 1996. At our institution, we reported similar results with a 33% hospital survival prior to 1981–1995 (21 of 64), and a 50% hospital survival from 1995–2001 (37 of 74) [2Kolovos N.S. Bratton S.L. Moler F.W. et al.Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery.Ann Thorac Surg. 2003; 76: 1435-1441Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar, 3Kulik T.J. Moler F.W. Palmisano J.M. et al.Outcome-associated factors in pediatric patients treated with extracorporeal membrane oxygenator after cardiac surgery.Circulation. 1996; 94: II63-II68PubMed Google Scholar]. As with this article, our experience likely improved from a multitude of reasons. However, in contradistinction to the conclusions of this report, one of the factors that seemed to contribute to the improvement at our institution was the cessation of the rapid deployment component of our ECMO program. Although there were differences in the type of support in that our program used a standard ECMO circuit, I would suspect that proper and timely patient selection was equally, if not more important than the apparatus used. Another important option for patients with cardiac failure and preserved pulmonary function are the various pediatric ventricular assist devices (VADs). Although only available on a compassionate use basis in North America, one of the more promising devices seems to be the Berlin Heart (Berlin Heart AG, Berlin). The Berlin Heart has been used extensively in Europe and has been implanted in North America in 52 cases. The pump for this device is available in graded volumes from 10 to 60 mL, which is appropriate for patients from neonates up to 60 kg. A recent report of the patients receiving the Berlin Heart in North America has shown encouraging results with an overall hospital survival of 82% (43 of 52) [4Mueller J, Buchholz H, Kroslowitz B, et al. The North American experience with the Berlin Heart Pump. The 6th Annual Cardiac Research Symposium. The Nemours Cardiac Center. April 28, 2006, Wilmington, Delaware.Google Scholar]. Hospital survivals for patients undergoing biventricular support after ECMO was 69% (9 of 13), without prior ECMO it was 92% (12 of 13), with left-sided VAD after ECMO it was 88% (7 of 8), and with left-sided VAD without previous ECMO it was 83% (15 of 18). Overall the results of the repair of complex congenital cardiovascular malformations have improved. Many lesions previously palliated are now primarily repaired in the neonatal period. With these changes a certain percentage of patients will require initial support as either a bridge to recovery or unfortunately also as a bridge to transplantation. Other groups use ECMO support as a standard part of postoperative management for stage 1 palliation for hypoplastic left heart syndrome [5Ungerleider R.M. Shen I. Yeh T. et al.Routine mechanical ventricular assist following the Norwood procedure–improved neurologic outcome and excellent hospital survival.Ann Thorac Surg. 2004; 77: 18-22Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar]. As experience accumulates and technology improves, either as modification of standard ECMO or as innovative devices, the outlook for our patients will continue to improve. Rapid Cardiopulmonary Support in Children With Heart Disease: A Nine-Year ExperienceThe Annals of Thoracic SurgeryVol. 82Issue 5PreviewWe developed a novel mechanical rapid cardiopulmonary support system (CPS) in 1996 to eliminate what we believed were shortcomings of conventional extracorporeal membrane oxygenation (ECMO) circuits when used in patients with congenital heart disease. We reviewed the use of this system over a nine year period to determine if we had been successful in improving results compared with ECMO and if outcomes have changed over this time. Full-Text PDF