Outcomes of Repeat Cardiac Extracorporeal Membrane Oxygenation Utilization in Pediatric Cardiac Patients: Analysis of Extracorporeal Life Support Organization Registry

Abstract

Need for repeat ECMO runs in pediatric cardiac patients often indicates underlying ongoing cardiac pathology. However the utilization and outcomes of multiple ECMO runs are not well described. We analyzed the Extracorporeal Life Support Organization (ELSO) registry database to assess the utilization, impact and outcomes of repeat cardiac ECMO runs (2012-2018). A total of 887 cardiac patients with multiple runs of ECMO were reported. Of these 756 had 2 runs, 116 had 3 runs, 14 with 4 runs and 1 patient had 5 runs of ECMO. Overall survival was 38.2% (339/887). Patients with 3 runs or more had a survival of 29% (39/131). Univariate analysis showed that age less than 1 month compared to over 1 month, non-Caucasian race, lower pH pre ECMO, lower oxygen saturation pre ECMO were associated with non-survival while age > 1 year compared to less than 1 year was protective. Survivors were more likely to have shorter initial ECMO run [89 (54-148) hours vs 115 (70-170) hours, p < 0.01] and shorter total ECMO run hours [216 (143-314) hours vs 301 (198-438)hours, p <0.01] . Neurologic and renal complications and need for inotropes during ECMO were significantly higher in non-survivors (all p<0.01). Multivariable regression analysis showed age < 1 month compared to >1 month [OR 1.96, CI 1.15-3.3, p <0.0001], age > 1 year compared to < 1 year [OR 0.37, CI 0.18 -0.73, p=0.0002] , cardiac ECMO vs ECPR as a reason for subsequent ECMO run [OR 0.57, CI 0.33-0.96, p=0.035] , ECMO total run of more than 300 hours [OR 3.2, CI 2.0-5.1, p < 0.0001], renal complications [OR 3.6, CI 2.2-5.8, p <0.0001] and neurologic complications [OR 4.68, CI 2.4-8.9, p <0.0001] were all associated with non-survival. This is the largest study of multiple ECMO runs in cardiac patients and showed an overall survival of 38%, which is lower than first run ECMO support and survival declines rapidly thereafter with subsequent runs. Need for ECPR and younger age at subsequent ECMO are associated with very poor survival. Ongoing assessment of support adequacy, end organ function and cardiopulmonary recovery is necessary as longer support and emerging complications are associated with poor survival. These findings may guide decision making regarding utility of multiple ECMO runs in a given patient.