Application Of Extracorporeal Life Support Research Articles

Extracorporeal membrane oxygenation (ECMO) in pregnancy and peripartum: a focused review

As the medical complexity of pregnant patients increases, the rate of maternal morbidity has risen. Maternal cardiovascular disease is a leading cause of maternal morbidity and mortality followed closely by sepsis and infection, both of which may be associated with respiratory failure. There has been an expansion in the application of extracorporeal life support in pregnant and peripartum patients which requires obstetric anesthesiologists to understand the indications, obstetric and medical considerations, relative advantages and potential complications of this invasive technology in this population. Obstetricians and anesthesiologists who care for women on the labor floor must strive to recognize at-risk and deteriorating patients, facilitate escalation of care when appropriate, and engage consultant teams to consider the need for extracorporeal support in high-risk circumstances. This article reviews the epidemiology, indications, specific considerations, potential complications, and outcomes of extracorporeal life support in pregnant and peripartum patients.

Role of extracorporeal life support in thoracic surgery

Besides the conventional extracorporeal circulation, commonly used in cardiac surgery, the methods of extracorporeal life support (ECLS) have been applied ever more frequently in thoracic surgery in recent years. The most commonly used modalities of such supports include extracorporeal membrane oxygenation (ECMO) and the Novalung interventional lung assist device (iLA). Successful application of ECLS has led to its more frequent use in general thoracic surgery, especially as atool to treat hypercapnia and to ensure oxygenation and haemodynamic support. However, these methods are essential in lung transplant programmes; without their help, in most cases, it would not be possible to perform the transplantation or prevent the severe complications associated with critical primary graft dysfunction. Additionally, the extracorporeal circulation also facilitates the performing of specific surgical procedures that would not be feasible under standard conditions or would be associated with an inadequate risk. The application of extracorporeal life supports can fundamentally increase the level of resection when treating advanced intrathoracic malignancies that are in close contact with the heart and large vessels or even directly extend into them. Without the possibility of resecting such structures en bloc, together with the tumour, and, thus, achieving an R0 resection, these malignant tumours are often directly contraindicated for surgery or are operated non-radically, i.e. unsuccessfully. Complete tumour resection is the most important prognostic factor in the surgery.

The Role of Extracorporeal Life Support in Thoracic Surgery

Extracorporeal life support (ECLS) is a widely used potential treatment option in patients with severe respiratory or cardiac failure with increasing significance. Routine perioperative application of ECLS is applied in cardiac and rare in thoracic surgery. This review will address the extracorporeal membrane oxygenation (ECMO) technology and basic concepts, the indications in thoracic surgery, and the intraoperative management of ECMO during surgery. The most common challenges and complications, the postoperative concept, and additional forms of support will be discussed. Technological advances in ECMO components may allow complex thoracic surgical procedures in patients in whom one-lung ventilation cannot be carried out safely without risk of hypoxia or right ventricular failure. The indications of ECLS in thoracic surgery besides lung transplantation are mainly airway resection and reconstructive surgery in patients with obstructive tracheobronchial airway diseases. Rare indications are lung surgery in patients with poor pulmonary reserve and difficulty or impossibility of one-lung ventilation. The intraoperative management of ECMO during thoracic surgery needs professional expertise.

Understanding the Current Role and Future Application of Extracorporeal Life Support in Acute Respiratory Distress Syndrome.

Understanding the Current Role and Future Application of Extracorporeal Life Support in Acute Respiratory Distress Syndrome.

Extracorporeal life support bridge for pulmonary hypertension: A high-volume single-center experience.

Application of extracorporeal life support (ECLS) for advanced pulmonary hypertension (PH) is evolving and may be deployed as a bridge to transplantation (BTT) or in one of several non-BTT uses, such as bridge to recovery (BTR) to the chronic PH clinical state in the setting of an acute PH trigger, bridge through non-transplant surgery (BTNTS), or bridge post-transplantation (BPT). We conducted a retrospective analysis of all adult patients with World Symposium on Pulmonary Hypertension Group 1, 3, 4, or 5 PH who received ECLS at Columbia University Medical Center/New York Presbyterian Hospital between January 1, 2010 and August 18, 2018. We describe patient characteristics, outcomes, and our approach to medical and surgical management of these patients. There were 98 patients with significant PH in the cohort (54 female; median age, 48 years [interquartile range, 32-58]). Of these, 44 (45%) patients with PH received ECLS as non-BTT with intent to recover back to their baseline functional state, optimize therapy, or support through a definitive surgery, including 19 BTR, 17 BTNTS, and 8 BPT, and 54 (55%) patients received ECLS as BTT. In the overall cohort, 67 (68.4%) patients received venoarterial ECLS and 31 (31.6%) received venovenous (VV) ECLS. Out of 83 patients, 52 (63%) were liberated from invasive mechanical ventilation, and 85.2% of BTT patients with PH ambulated while on ECLS. Management of PH medications was individualized, often requiring titration with use of inhaled pulmonary vasodilators increased after cannulation in non-BTT. Overall 30-day survival was 73.5%, survival to ECLS decannulation was 66.3%, and survival to hospital discharge was 54.1%. All 8 BPT patients (100%) survived to hospital discharge, 64.7% of BTNTS patients survived to hospital discharge, and 32 (59.3%) BTT patients survived to lung transplantation. Early-era use of VV-ECLS for BTT had worse survival to discharge than those initially configured with venoarterial ECLS, impacting the overall survival and leading to limited use of VV-ECLS in the current era for BPT, BTNTS, and select BTR cases. ECLS instituted by a specialized, multidisciplinary team has a role in the management of advanced PH as BTT or as non-BTT (including BTR, BTNTS, and BPT). Careful selection of ECLS cannulation configurations, patient-specific optimization of PH medical therapies, and avoidance of endotracheal intubation may be effective strategies in managing these complex patients.

Medical and Surgical Management of ECLS as Bridge to Recovery and Transplantation for Pulmonary Hypertension: A Large Single Center Experience

Purpose Despite advanced targeted medical therapy, patients with pulmonary hypertension (PH) can experience gradual or sudden progression of their symptoms due to an acute insult. Application of extracorporeal life support (ECLS) for advanced PH is evolving. We examined our single-center experience using ECLS as bridge to recovery (BTR), non-transplant surgery (BTNTS), or lung transplantation (BTT) in patients with PH. Methods We conducted a retrospective analysis of all adult patients with non-WHO group 2 PH who received ECLS at New York Presbyterian - Columbia University Medical Center between 2010 and 2018. We describe clinical characteristics and our specialized approach to medical and surgical management in this cohort. Results There were 98 PH patients in the cohort (54 female; median age 48 years (IQR 32-58)). Thirty-six (36.7%) patients received ECLS with intent to BTR (including 10 BTNTS) and 62 (63.3%) to BTT, including 8 who received ECLS during or immediately after lung transplantation. In the overall cohort, 58 (59.1%) patients received VA-ECLS, including upper body Sport Model (n=13), and upper body Central Sport Model (n=7). Nine (9.2%) patents received VVA-ECLS. Thirty-two (32.7%) patients received VV-ECLS including 4 via a congenital pulmonary-systemic shunt for “VA” physiology. Serum lactate, creatinine, brain natriuretic peptide, and arterial blood gas measures improved after ECLS cannulation. Sixty-eight (70%) patients were liberated from invasive mechanical ventilation while receiving ECLS. Management of PH medications followed an intentional strategy of de-escalation for BTT and ramp down and then ramp up for non-surgical BTR. PH medications including intravenous and inhaled prostanoids, endothelin receptor antagonists, and phosphodiesterase 5 inhibitors were used most often in BTR patients and in WHO group 1 PH BTT patients. Survival to decannulation in this cohort was 85.7%; 30-day survival was 71.4%. Conclusion ECLS instituted by a specialized, multidisciplinary PH/ECLS team has a growing role in the management of advanced non-WHO group 2 PH as BTR, BTNTS, or to BTT. Careful selection of cannulation configurations, patient-specific optimization of PH medical therapies, and avoidance of endotracheal intubation may be an effective strategy in managing these complex patients.

Extracorporeal Life Support in Acute Poisoning

Purpose: Cardiovascular or respiratory complications of acute intoxication are the most common causes of mortality. Advanced cardiac life support (ACLS) or specific antidotes help manage these cardiac or respiratory complications in acute intoxication. On the other hand, some cases do not respond to ACLS or antidotes and they require some special treatment, such as extracorporeal life support (ECLS). ECLS will provide the chance of recovery from acute intoxication. This study examined the optimal timing of ECLS in acute intoxication cases. Methods: This paper is a brief report of a case series about ECLS in acute poisoning. The cases of ECLS were reviewed and the effects of ECLS on the blood pressure and serum lactate level of the patients were analyzed. Results: A total of four cases were reviewed; three of them were antihypertensive agent-induced shock, and one was respiratory failure after the inhalation of acid. The time range of ECLS application was 4.8-23.5 hours after toxic exposure. The causes of ECLS implementation were one for recurrent cardiac arrest, two for shock that did not respond to ACLS, and one for respiratory failure that did not respond to mechanical ventilator support. Three patients showed an improvement in blood pressure and serum lactate level and were discharged alive. In case 1, ECLS was stared at 23.5 hours post toxic exposure; the patient died due to refractory shock and multiple organ failure. Conclusion: The specific management of ECLS should be considered when a patient with acute intoxication does not recovery from shock or respiratory failure despite ACLS, antidote therapies, or mechanical ventilator support. ECLS improved the hemodynamic and ventilator condition in complicated poisoned patients. The early application of ECLS may improve the tissue perfusion state and outcomes of these patients before the toxic damage becomes irreversible.

Adult veno-arterial extracorporeal life support

Extracorporeal life support (ECLS)/extracorporeal membrane oxygenation (ECMO) is a powerful tool in the surgeon's armamentarium. The rapid evolution of ECLS over the last four decades has improved survival in patients with cardiopulmonary failure. With the pandemic outbreak of H1N1 in 2009 and onward, the application of ECLS has only risen. Yet, amongst the outcomes reporting and improved survival, the water remains hazy in terms of outcome predictors as well as discovery of the "ideal" system. There remains much room for innovation and research related to circuit construction, ideal flow, myocardial recovery, and additional applications of ECLS. We present a review on the topic of veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

Advanced extracorporeal therapy in trauma.

The purpose is to review the current application of extracorporeal life support (ECLS) in trauma patients. In addition, programmatic development is described. ECLS use is increasing among trauma patients. Several recent studies among trauma patients report survival rates of 65-79%. Despite the high bleeding risk, extracorporeal membrane oxygenation (ECMO) may be safely implemented in trauma patients based on a strict protocol-driven policy. Early implementation may improve overall outcomes. Alternative anticoagulants and heparin free periods may be well tolerated in trauma patients at high risk of hemorrhage. ECMO is becoming a more routine option in severely injured trauma patients that develop severe respiratory failure. Well tolerated implementation and program development is possible among regional trauma centers. Although clinical knowledge gaps exist, ECMO is a promising treatment in this high-risk population.

Current and future status of extracorporeal life support for respiratory failure in adults.

The purpose is to review the development and current application of extracorporeal life support [ECLS, extracorporeal membrane oxygenation (ECMO)] in acute severe respiratory failure. Extracorporeal support (ECMO) is used for acute severe respiratory failure in advanced ICUs. The current survival rate is 60-70%. Three controlled trials all demonstrated 20-30% improvement in survival compared to conventional care. Patients may now be maintained awake and ambulatory with spontaneous breathing. ECMO is the next step in the algorithm for management of severe respiratory failure unresponsive to conventional care.

Early Extracorporeal Membrane Oxygenation for Massive Aspiration during Anesthesia Induction

Although the incidence is not high in the general surgical population, pulmonary aspiration of gastric contents can result in serious long-term morbidity and mortality. We report a case of early use of extracorporeal membrane oxygenation (ECMO) to correct severe hypoxemia refractory to conventional mechanical ventilation in a patient with massive aspiration of gastric contents immediately followed by acute lung injury during general anesthesia induction. A 64-year-old woman diagnosed with stomach cancer was scheduled for elective diagnostic laparoscopy. Although there was no sign of gastrointestinal tract obstruction and midnight Nil per Os (NPO) was performed before the operation, pulmonary aspiration occurred during the induction of anesthesia. Despite the endotracheal intubation with mechanical ventilation, severe hypoxemia with hypercapnea persisted. Medical team agreed with applying veno-venous (VV) ECMO, and her blood gas analysis results became stable. ECMO was weaned successfully 9 days after the first aspiration event had occurred. Based on this case, early application of extracorporeal life support can have survival benefits.

Results of extracorporeal life support implementation in routine clinical practice: single center experience.

AimTo describe our experience in the clinical application of extracorporeal life support (ECLS) and analyze whether ECLS leads to acceptable clinical outcomes in patients with cardiac failure.MethodsData from clinical database of University Hospital Center Zagreb, Croatia, on 75 patients undergoing ECLS support from 2009 to 2014 due to cardiac failure were retrospectively analyzed. Outcomes were defined as procedural and clinical outcomes. ECLS as a primary procedure and ECLS as a postcardiotomy procedure due to inability to wean from cardiopulmonary bypass were analyzed.ResultsECLS was used in 75 adult patients, and in 24 (32%) of those procedural success was noted. ECLS was implemented as a primary procedure in 36 patients and as a postcardiotomy procedure in 39 patients. Nine out of 39 (23.08%) patients had postcardiotomy ECLS after heart transplantation. Bleeding complications occurred in 30 (40%) patients, both in primary (11/36 patients) and postcardiotomy group (19/39 patients). ECLS was established by peripheral approach in 46 patients and by central cannulation in 27 patients. In 2 patients, combined cannulation was performed, with an inflow cannula placed into the right atrium and an outflow cannula placed into the femoral artery. Eleven patients treated with peripheral approach had ischemic complications.ConclusionECLS is a useful tool in the treatment of patients with refractory cardiac failure and its results are encouraging in patients who otherwise have an unfavorable prognosis.

Extracorporeal life support in critically ill adults.

Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.

Extra-corporeal life support following cardiac surgery in children: analysis of risk factors and survival in a single institution

Application of extra-corporeal life support (ECLS) following pediatric cardiac surgery varies between different institutions based on manpower availability and philosophy towards ECLS utilization. We examined a large single institution experience with postoperative ECLS in children aiming to identify outcome predictors. Hospital records of all children who required postoperative ECLS at our institution were reviewed. Patients' demographics, cardiac anatomy, surgical and ECLS support details were entered into a multivariable regression analysis to determine factors associated with survival. Between 1990 and 2007, 180 consecutive children, median age 109 days (range: 1 day-16.9 years), required postoperative ECLS. Sixty-nine children (38%) had undergone palliative treatment for single ventricle pathology. ECLS support was required for failure to separate from cardiopulmonary bypass (n=83) or for postoperative low cardiac output state (n=97). Forty-eight patients (27%) received rescue extra-corporeal membrane oxygenation (ECMO) support during active chest compression for refractory cardiac arrest. Under ECLS support, 37 patients required surgical revision and 20 received orthotopic heart transplantation. One hundred and nine patients (61%) survived >24h following ECLS discontinuation and 68 (38%) were discharged alive. Hospital survivors required shorter ECLS support duration compared to non-survivors (median 3 vs 5 days, respectively, p=0.05) however survival occurred after up to 16 days of ECLS support. ECLS indication (OR: 0.85 for failure to separate from bypass vs postoperative low cardiac output 95% CI (0.47-1.56), p=0.62) and rescue ECMO (OR: 0.63 for rescue ECMO vs not 95%CI (0.32-1.24), p=0.18) were not associated with risk of mortality. In a multivariable logistic regression model, neurological complications (p=0.0007), prolonged ECLS duration (p=0.003), repeat ECLS requirement (p=0.02), renal dysfunction (p=0.04) and not performing heart transplantation (p=0.04) were significant factors for hospital death. ECLS plays a valuable role in children with low cardiac output state following cardiac surgery. More than one third of those patients, including young neonates, older children, patients with single ventricle, or those requiring rescue ECMO can be salvaged. Although prognosis worsens with prolonged ECLS duration, survival can be noted up to 16 days of support. Heart transplantation is often an important ECLS exit strategy and should be considered early in selected children. Patients' survival could improve if renal and neurological complications are avoided.

Principle and application of extracorporeal life support

体外生命支持系统(ECLS)和传统定义的体外膜肺是一种改良的体外循环系统,用于对心肺衰竭患者提供长时间氧输送.它通过一种以循环血流泵与体外氧交换器为核心组成的人工体外循环装置,进行以体外替代性气体交换支持和心脏替代支持为目的的心肺支持,为那些可逆性的严重心肺功能障碍患者提供以肺功能支持为主的心肺支持.ECLS同时可以降低危重患者对其他心肺支持措施的要求,并仅需低参数机械通气,为肺功能的恢复赢得时间。

Extracorporeal life support

Extracorporeal life support (ECLS) denotes the use of prolonged extracorporeal cardiopulmonary bypass in patients with acute, reversible cardiac or respiratory failure. As technology has advanced, organ support functions other than gas exchange, such as liver, renal, and cardiac support, have been provided by ECLS, and others, such as immunologic support, will be developed. The future of ECLS will include improvements in devices accompanied by circuit simplification and auto-regulation. Such enhancements in technology will allow application of ECLS to populations currently excluded from such support; for example, thromboresistant circuits will eliminate the need for systemic anticoagulation and lead to the use of this technique in premature newborns. As the ECLS technique becomes safer and simpler, and as morbidity and mortality are minimized, criteria for application of ECLS will be relaxed. New approaches to ECLS, such as pumpless arteriovenous bypass, the artificial placenta, arteriovenous CO(2) removal (AVCO(2)R), and intravenous oxygenators (IVOX), will become more commonly applied. Such advances in technology will allow broader and more routine application of ECLS for lung and other organ system failure.

Back from Irreversibility: Extracorporeal Life Support for Prolonged Cardiac Arrest

The survival of patients after prolonged cardiac arrest is still inadequate. Extracorporeal life support (ECLS) represents an alternative therapeutic method for patients who do not respond to conventional cardiopulmonary cerebral resuscitation. This technology is used to support the circulation of a patient with severe cardiac failure. Between June 1997 and January 2003, 40 ECLS procedures were performed in patients who presented with refractory cardiac arrest. During external cardiac massage, the patient was connected to an extracorporeal circuit by the insertion of an arterial and venous cannula through the femoral vessels. The extracorporeal circuit included a centrifugal pump and an oxygenator. Mean age was 42 +/- 15 years; the average time of external cardiac massage was 105 +/- 44 minutes. Once the circulation was restored, 22 patients were disconnected from the extracorporeal circulation because of brain death or multiorgan failure; after 24 hours, among the 18 survivors, 6 were weaned off the pump, 9 were bridged to a ventricular assist device, and 2 patients were directly bridged to cardiac transplantation. Eight patients are alive and without any sequelae at 18 month's follow-up. In prolonged cardiac arrest with failing conventional measures, rescue by extracorporeal support provides an ultimate therapeutic option with a good outcome in survivors. Our results encourage the wider application of ECLS for refractory cardiocirculatory arrest in selected patients. The high rate of neurologic death needs further improvements in the early phase of resuscitation maneuvers.

The effect of pre-ECLS ventilation time on survival and respiratory morbidity in the neonatal population

Although mechanical ventilation for more than 7 to 10 days has been considered a contraindication to the application of extracorporeal life support (ECLS) in neonates, the outcome and respiratory morbidity for newborns placed on ECLS after more than 7 days of ventilation have not been well characterized. The purpose of this study was to determine the impact of pre-ECLS ventilation time on the rate of survival, the likelihood of the development of bronchopulmonary dysplasia (BPD), and the need for supplemental oxygen at the time of discharge. Examination of the Extracorporeal Life Support Organization (ELSO) Registry showed that 6,110 neonates were treated for respiratory failure with a pre-ECLS ventilation time of less than 14 days between January 1990 and May 1995. Gestational age (GA), birth weight (BW), indication for ECLS, and diagnosis were compared with the rate of survival, the discharge diagnosis of BPD, and the need for home oxygen. The GA and BW of neonates placed on ECLS during the first week of life (n = 5,888) did not differ significantly from those of neonates whose ECLS was begun in the second week of life (n = 222). The neonates were divided into two groups (early, ventilation time of 3 to 6 days; late, ventilation time of 7 to 10 days) to determine the odds ratios for survival, BPD, and home oxygen. Logistic regression analysis was used to develop a model to predict the rate of survival, the risk for the development of BPD, and the need for home oxygen given the length of pre-ECLS ventilation time. The late group was less likely to survive (odds ratio, 1.8; 95% confidence interval [Cl], 1.21 to 2.68). The late group also had approximately twice the risk for the development of BPD (odds ratio, 1.9; 95% Cl, 1.2 to 3.04) and a trend toward an increased incidence of home oxygen use (odds ratio, 1.55; 95% Cl, 0.92 to 2.60). The authors conclude that (1) there is a greater risk of mortality and BPD and a trend toward an increased need for home oxygen with increased time on the ventilator before ECLS; (2) at 14 days the predicted probability of survival is still 53% (95% Cl, 31% to 74%); (3) at 14 days the predicted probability of BPD is 54% (95% Cl, 28% to 78%); and (4) based on these data, it is reasonable to consider application of ECLS to patients who have had mechanical ventilation for up to 14 days.

Extracorporeal life support for neonatal respiratory failure. A 20-year experience.

The authors reviewed their experience with extracorporeal life support (ECLS) in neonatal respiratory failure; they define changes in patient population, technique, and outcomes. Extracorporeal life support has progressed from laboratory research to initial clinical trials in 1972. Following a decade of clinical research, ECLS is now standard treatment for neonatal respiratory failure refractory to conventional pulmonary support techniques. Our group has the longest and largest experience with this technique. Between 1973 and 1993, 460 neonates with severe respiratory failure were treated using ECLS. The records of all patients were reviewed. Overall survival was 87%. Primary diagnoses were meconium aspiration syndrome (MAS; 169 cases [96% survival]), respiratory distress syndrome/hyaline membrane disease (91 cases [88% survival]), persistent pulmonary hypertension of the newborn (37 cases [92%]), pneumonia/sepsis (75 cases [84% survival]), congenital diaphragmatic hernia (CDH; 67 cases [67% survival]), and other diagnoses (21 cases [71% survival]). Common mechanical complications included clots in the circuit (136; 85% survival); air in the circuit (67; 82% survival); cannula problems (65; 83% survival) and oxygenator failure (34; 65% survival). Patient-related complications included intracranial infarct or bleed (54 cases; 61% survival), major bleeding (48 cases; 81% survival), seizures (88 cases; 76% survival), metabolic abnormalities (158 cases; 71% survival) and infection (21 cases; 48% survival). Since 1989, treatment groups have been expanded to include premature infants (13 cases; 62% survival), infants with grade I intracranial hemorrhage (28 cases; 54% survival) and "non-honeymoon" CDH patients (15 cases; 27% survival). Since 1990, single-catheter venovenous access has been used in 131 patients (97% survival) and currently is the preferred mode of access. Follow-up ranges from 1 to 19 years; 80% of patients are growing and developing normally. Extracorporeal life support has become standard treatment for severe neonatal respiratory failure in our center (460 cases; 87% survival), and worldwide (8913 cases; 81% survival). The availability of ECLS makes the evaluation of other innovative methods of treatment, such as late elective repair of diaphragmatic hernia and new pulmonary vasodilators, possible. The application of ECLS is now being extended to premature and low-birth weight infants as well as older children and adults.

Effect of extracorporeal life support on survival when applied to all patients with congenital diaphragmatic hernia

Extracorporeal life support (ECLS) has been used for neonates with congenital diaphragmatic hernia (CDH) and respiratory failure at the authors' hospital since June 1981. In 1988, criteria for inclusion in ECLS were broadened to include “nonhoneymoon” infants (honeymoon: best postductal Pa o 2 of > 50 mm Hg). To evaluate the impact of this approach on the treatment of CDH, the authors reviewed the records of all newborns managed at their institution, since the availability of ECLS in 1981, who were symptomatic with CDH in the first 24 hours of life (n = 111). The patients were divided chronologically into two groups: 1981 to 1987 (early ECLS, n = 36) and 1988 to 1993 (expanded ECLS, n = 75). The data demonstrate that the number of CDH patients managed at our institution each year has increased (1981 to 1987 = 6, 1988 to 1993 = 14) as has the severity of associated respiratory insufficiency (% of patients with best Pa o 2 of ≤ 50 mm Hg: 1981 to 1987 = 6%, 1988 to 1993 = 28%). Overall, the survival rate was lower for patients in the expanded ECLS group (59% v 75%; P = .121). When the survival rates for patients supported with ECLS postoperatively were compared for the expanded and early groups, a significant difference (59% v 80%; P < .05) was noted. However, when ECLS patients with a best Pa o 2 of ≤ 50 mm Hg were excluded from this analysis, there was no significant difference between the two groups (74% v 80%), indicating that the inclusion of nonhoneymoon patients as potential ECLS candidates has accounted for a significant portion of the observed decrease in survival among CDH patients managed with ECLS. The survival rate of salvageable CDH patients with a best Pa o 2 of ≤ 50 mm Hg increased slightly for the expanded ECLS group, to 27% (4 of 15), versus 0% (0 of 2) for the early ECLS group. The authors conclude that a change in the population of CDH patients presenting to their institution along with application of ECLS to CDH patients without a honeymoon has resulted in a reduction in the survival rate, but has allowed only a modest 27% survival rate for patients who were previously considered nonsalvageable.