Pediatric Cardiac Patients with Pulmonary Hemorrhage supported on ECMO: an ELSO Registry study

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Background: Pulmonary hemorrhage (PH) is a rare but potentially devastating condition and pediatric cardiac patients are at increased risk for. ECMO may be used to safely support these patients, but data is limited. Methods: Observational retrospective cohort study from the ELSO Registry database in pediatric cardiac patients from birth to 18 years old with PH supported on ECMO from January 2011 through December 2020. The objectives of the study were to characterize pediatric cardiac patients with PH before ECMO and to describe factors associated with improved survival. Results: A total of 161 cardiac neonates and children with PH supported on ECMO were analyzed. Median age and weight were 40 days (IQR 7.3-452) and 4.06 kg (IQR 3-9.36), respectively. Congenital heart disease accounted for 77% of diagnoses. Survival to hospital discharge was 35.8%. Before ECMO cannulation, most patients were ventilated in conventional modes (79.7%), followed by high-frequency oscillatory (HFOV) ventilation (11%). There was a significantly higher use of HFOV pre-cannulation in survivors compared to non-survivors (24.4% vs 2.8%, p <0.001). Multivariable logistic regression demonstrated that HFOV before ECMO (OR 28.44, p <0.001) and the absence of hemorrhagic (OR 3.51, p 0.031) and renal (OR 3.50, p 0.027) complications were independent predictors for survival to hospital discharge. Conclusion: Utilization of HFOV before cannulation to ECMO seems to be associated with improved survival in pediatric cardiac patients with acute pulmonary hemorrhage. A prospective assessment of mechanical ventilation practices before ECMO may improve outcomes in this medically complex population.