Mechanical Cardiopulmonary Support Research Articles

Rescue extracorporeal membrane oxygenation for refractory cardiogenic shock.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used for bridge-to-recovery, bridge-to-decision or bridge to ventricular assist device (VAD) implantation or heart transplantation in patients with cardiogenic shock (CS). We report a case of iatrogenic left main coronary artery (LMCA) dissection and secondary cardiogenic shock in which mechanical cardiopulmonary support with portable ECMO was used to rescue the patient after urgent surgical revascularization. Extracorporeal membrane oxygenation has the potential to improve tissue perfusion without the adverse consequences of medical therapies, consisting primarily of inotropic agents and vasopressors, such as increased myocardial oxygen demand and ischemia, arrhythmogenicity and reduction of tissue microcirculation, creating the opportunity to reduce the high mortality rates currently associated with conventionally managed patients in CS.

Comparison of extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation

This study compared differences in patient outcomes and operative parameters for extracorporeal membrane oxygenation (ECMO) versus cardiopulmonary bypass (CPB) in patients undergoing lung transplants. Between January 1, 2008, and July 13, 2013, 316 patients underwent lung transplants at our institution, 102 requiring intraoperative mechanical cardiopulmonary support (CPB, n=55; ECMO, n=47). We evaluated survival, blood product transfusions, bleeding complications, graft dysfunction, and rejection. Intraoperatively, the CPB group required more cell saver volume (1123±701 vs 814±826 mL; P=.043), fresh-frozen plasma (3.64±5.0 vs 1.51±3.2 units; P=.014), platelets (1.38±1.6 vs 0.43±1.25 units; P=.001), and cryoprecipitate (4.89±6.3 vs 0.85±2.8 units; P<.001) than the ECMO group. Postoperatively, the CPB group received more platelets (1.09±2.6 vs 0.13±0.39 units; P=.013) and was more likely to have bleeding (15 [27.3%] vs 3 [6.4%]; P=.006) and reoperation (21 [38.2%] vs 7 [14.9%]; P=.009]. The CPB group had higher rates of primary graft dysfunction at 24 and 72 hours (41 [74.5%] vs 23 [48.9%]; P=.008; and 42 [76.4%] vs 26 [56.5%]; P=.034; respectively). There were no differences in 30-day and 1-year survivals. Relative to CPB, the ECMO group required fewer transfusions and had less bleeding, fewer reoperations, and less primary graft dysfunction. There were no statistically significant survival differences at 30 days or 1 year.

Management of pediatric tachyarrhythmias on mechanical support.

Pediatric patients with persistent arrhythmias may require mechanical cardiopulmonary support. We sought to classify the population, spectrum, and success of current treatment strategies. A multicenter retrospective chart review was undertaken at 11 sites. Inclusion criteria were (1) patients <21 years, (2) initiation of mechanical support for a primary diagnosis of arrhythmias, and (3) actively treated on mechanical support. A total of 39 patients were identified with a median age of 5.5 months and median weight of 6 kg. A total of 69% of patients were cannulated for supraventricular tachycardia with a median rate of 230 beats per minute. A total of 90% of patients were supported with extracorporeal membrane oxygenation for an average of 5 days. The remaining 10% were supported with ventricular assist devices for an average of 38 (20-60) days. A total of 95% of patients were treated with antiarrhythmics, with 43% requiring >1 antiarrhythmic. Amiodarone was the most frequently used medication alone or in combination. A total of 33% patients underwent electrophysiology study/transcatheter ablation. Radiofrequency ablation was successful in 9 patients on full flow extracorporeal membrane oxygenation with 3 radiofrequency-failures/conversion to cryoablation. One patient underwent primary cryoablation. A total of 15% of complications were related to electrophysiology study/ablation. At follow-up, 23 patients were alive, 8 expired, and 8 transplanted. Younger patients were more likely to require support in the presented population. Most patients were treated with antiarrhythmics and one third required electrophysiology study/ablation. Radiofrequency ablation is feasible without altering extracorporeal membrane oxygenation flows. There was a low frequency of acute adverse events in patients undergoing electrophysiology study/ablation, while on extracorporeal membrane oxygenation.

Artificial Organs2013: A Year in Review

In this Editor's Review, articles published in 2013 are organized by category and briefly summarized. We aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, the International Society for Rotary Blood Pumps, the International Society for Pediatric Mechanical Cardiopulmonary Support, and the Vienna International Workshop on Functional Electrical Stimulation, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level". Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide so meaningful suggestions to the author's work whether eventually accepted or rejected and especially to those whose native tongue is not English. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, Wiley Periodicals, for their expert attention and support in the production and marketing of Artificial Organs. We look forward to recording further advances in the coming years.

Fulminant myocarditis in a patient with severe coronary artery disease

A 55-year-old man complaining of fever and exertional dyspnea was admitted for coronary angiography to differentiate between fulminant myocarditis and acute coronary syndrome. He had been treated for 17 years for angina pectoris. His electrocardiogram demonstrated ST segment changes in almost all leads. Cardiac catheterization demonstrated severe stenosis in the left descending artery, the diagonal branch, and the right coronary artery. Ultrasonography, however, revealed diffuse hypokinesis of the left ventricle and edematous wall thickening, suggesting fulminant myocarditis. This is the first report in which a patient with fulminant myocarditis with severe coronary artery disease was successfully treated with mechanical cardiopulmonary support, intensive pharmacological therapy, and staged coronary intervention procedures. Complicated coronary artery disease may delay the diagnosis of myocarditis and worsen the clinical outcome. Patients having fulminant myocarditis with coronary artery disease need careful diagnosis, and percutaneous cardiopulmonary support should be considered in the early clinical stage.<Learning objective: Complicated coronary artery disease may delay the diagnosis of myocarditis and worsen the clinical outcome. It is considered safe to use percutaneous cardiopulmonary support for such patients in the early clinical stage. The present case was rescued with mechanical support in the acute phase of fulminant myocarditis and elective coronary angioplasty in the recovery phase.>

Longer operative time is associated with higher risk of severe complications after percutaneous nephrolithotomy: Analysis of 1511 cases from a Japanese nationwide database

To evaluate risk factors of severe adverse events after percutaneous nephrolithotomy with an emphasis on operation time, and to develop a nomogram for predicting them. This was an observational retrospective study including 1511 patients who underwent percutaneous nephrolithotomy in 332 hospitals identified from the Japanese Diagnosis Procedure Combination database between 2007 and 2010. Severe adverse events were defined as follows: (i) in-hospital mortality; (ii) postoperative medications including catecholamine, gamma-globulin products, protease inhibitors and medications for disseminated intravascular coagulation; and (iii) postoperative interventions including central vein catheterization, dialysis and mechanical cardiopulmonary support. Univariate and multivariate logistic regression analyses were carried out for the occurrence of severe adverse events, and a nomogram was generated from this model. Overall, 126 severe adverse events (8.34%) were identified. In the multivariate model, a linear trend between severe adverse events and operation time was observed (OR 4.72 for 120-179 min to 17.95 for ≥300 min compared with ≤119 min; each P < 0.05) after adjustment for sex, age, Charlson Comorbidity Index and type of admission. Female sex and emergency admission were also significant risk factors (OR 1.92 and 2.04, respectively), and hospital volume did not reach statistical significance. The nomogram based on these results was well fitted to predict a probability between 0.05 and 0.40 (concordance index 0.696). Longer operation time is a significant and independent risk factor for severe adverse events after percutaneous nephrolithotomy. Our nomogram can be an effective tool for predicting postoperative complications.

Expanding the Availability of Extracorporeal Cardiopulmonary Resuscitation

A healthy 14-year-old presented to an emergency department in Alaska, complaining of shortness of breath, chest pain, and 72 hours of malaise and headache. On admission, her blood pressure was 80/50 mm Hg, and she had cool extremities. Electrocardiography revealed wide-complex ventricular tachycardia. She underwent synchronized electrical cardioversion. Although she initially converted to sinus rhythm, she subsequently became pulseless, with electrocardiographic evidence of ventricular tachycardia. Despite cardiopulmonary resuscitation, she failed to achieve a perfusing rhythm. Cardiovascular surgery consultation was obtained, and she was placed on partial cardiopulmonary bypass during 2 hours of ongoing chest compressions. Cardiopulmonary bypass flow was limited by the small size of her femoral arteries. She remained in refractory ventricular tachycardia. The cardiopulmonary bypass circuit was modified for transportation of the patient via air ambulance 1500 miles to a tertiary medical center that specializes in pediatric heart failure and mechanical cardiopulmonary support. Upon arrival at the tertiary medical center, she underwent carotid artery cannulation to improve total cardiopulmonary support and percutaneous balloon atrial septostomy to facilitate left ventricular decompression. Intravenous immunoglobulin and steroids were administered to treat presumed acute fulminant viral myocarditis. Extracorporeal life support was support was successfully discontinued after 14 days, but she experienced a thromboembolic stroke. The patient was discharged on hospital day 65 with moderate generalized left-sided weakness, but she was able to ambulate with minimal assistance. She subsequently returned to school and is progressing appropriately with her peers. Cardiac function has normalized, and she remains in normal sinus rhythm.

International Society for Pediatric Mechanical Cardiopulmonary Support Selects Artificial Organs as Its Official Journal

International Society for Pediatric Mechanical Cardiopulmonary Support Selects <i>Artificial Organs</i> as Its Official Journal

A nomogram predicting severe adverse events after ureteroscopic lithotripsy: 12 372 patients in a Japanese national series

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Ureteroscopic lithotripsy sometimes causes severe complications, e.g. septic shock, and the relationship between long operative duration and complication rate has been empirically recognised. But due to the rarity, evidence is limited. We analysed 12372 cases and showed that the complication rate increased according to operative duration, especially for operations taking >90 min. Also, we found that high-volume centres had lower complication rates. To develop a nomogram to predict severe adverse events (AEs) after ureteroscopic lithotripsy (URSL) including the effects of operative duration and hospital volume. We identified patients undergoing URSL from the Japanese Diagnosis Procedure Combination database between 2007 and 2010, and defined severe adverse events as (i) in-hospital mortality; (ii) postoperative medication including catecholamine, γ globulin, protease inhibitors, medications for disseminated intravascular coagulation and transfusion; and (iii) postoperative interventions including percutaneous nephrostomy, central vein catheterisation, intensive care unit, dialysis, mechanical cardiopulmonary support. Univariate and multivariate logistic regression models addressed the occurrence of severe AEs. Of 12 372 patients, 296 patients (2.39%) had severe AEs. Multivariate analysis showed a positive linear trend of operative duration and severe AEs (odds ratio [OR] 1.58 in 90-119 min to OR 4.28 in ≥210 min compared with ≤ 59 min; each P < 0.05) and an inverse relationship between hospital volume and severe AEs (OR 0.64 in ≥39 URSLs/year compared with ≤ 15 URSLs/year; P = 0.004) with adjustment for other significant factors including sex, age, Charlson comorbidity index, type of anaesthesia and type of admission. A nomogram and a calibration plot based on these results were well-fitted to predict a probability between 0.01 and 0.10 (concordance index 0.677). Severe AEs after URSL were associated with longer operative duration and lower hospital volume, and were accurately predicted using the present nomogram.

Myocarditis in a pediatric case of pandemic 2009H1N1 influenza

We report a 6-year-old boy with no major disease history or allergic conditions initially presented with pneumonia, progressed to acute respiratory distress syndrome and acute myocarditis caused by pandemic 2009H1N1 influenza diagnosed with RT-PCR testing, successfully managed with mechanical ventilation and percutaneous cardiopulmonary support system. Marked transient elevation of IgE in acute phase of the disease and the subsequent diagnosis of atopic asthma in our patient suggested a possible role of an underlying allergic condition in the clinicopathological process. Critically ill 2009H1N1-infected patient with acute respiratory failure should carefully be physiologically monitored together with serial assessment of biomarkers aiming at a favorable cardiac outcome by giving the timely diagnosis and intervention.

Transbrachial intra-aortic balloon pumping for a patient with fulminant myocarditis

A 57-year-old man with acute myocarditis was transferred to our hospital from a local clinic. The patient experienced unexpected sudden cardiac arrest 16 h after admission. Mechanical cardiopulmonary support was started using percutaneous cardiopulmonary support, intra-aortic balloon pumping (IABP), continuous hemodialysis filtration, and temporary cardiac pacing with percutaneous cannulation of the femoral vessels. Hematoma developed at the IABP insertion site on the 5th day after admission. The IABP was removed, and another IABP system was inserted via the left brachial artery. The patient's condition improved, and the IABP was removed on the 9th day after admission. The remainder of the patient's in-hospital treatment was uneventful, and he showed near-normal left ventricular systolic function 1 year after discharge.

Outcomes of the Seventh International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion and Second Annual Meeting of the International Society for Pediatric Mechanical Cardiopulmonary Support

The Sixth International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion was held at the Joseph B. Martin Conference Center at Harvard Medical School in Boston, MA, USA, May 6–8, 2010 (1). The scientific cochairs of the pediatric event were Elizabeth D. Blume, MD, Boston, MA, USA; Pedro del Nido, MD, Boston, MA, USA; Giovanni Battista Luciani, MD, Verona, Italy; John L. Myers, MD, Hershey, PA, USA; Ulrich Steinseifer, PhD, Aachen, Germany; and Akif Undar, PhD, Hershey, PA, USA. Elizabeth D. Blume, MD, Medical Director, Heart Failure/Transplant Program of the Children’s Hospital Boston, was the local conference chair. Over 275 participants from 20 countries have enjoyed over 100 presentations, including invited lectures, slides, and posters presented at the Sixth Event. The conference Website has all the details including all past conference proceedings with presented abstracts as well as more information about the future events (http://www.hmc.psu.edu/childrens/pedscpb). Social and scientific evaluations of the conference were also outstanding for each category.

Outcomes of the Sixth International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion and First Annual Meeting of the International Society for Pediatric Mechanical Cardiopulmonary Support

Artificial OrgansVolume 34, Issue 11 p. 865-868 Outcomes of the Sixth International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion and First Annual Meeting of the International Society for Pediatric Mechanical Cardiopulmonary Support Akif Ündar PhD, Akif Ündar PhD Conference FounderProfessor of Pediatrics, Surgery, and BioengineeringFounder and Director, Penn State Hershey Pediatric Cardiovascular Research CenterFounder and President, International Society for Pediatric Mechanical Cardiopulmonary SupportDepartment of PediatricsPenn State Hershey College of MedicineH085, 500 University Drive, P.O. Box 850Hershey, PA 17033-0850, USAE-mail: aundar@psu.eduSearch for more papers by this author Akif Ündar PhD, Akif Ündar PhD Conference FounderProfessor of Pediatrics, Surgery, and BioengineeringFounder and Director, Penn State Hershey Pediatric Cardiovascular Research CenterFounder and President, International Society for Pediatric Mechanical Cardiopulmonary SupportDepartment of PediatricsPenn State Hershey College of MedicineH085, 500 University Drive, P.O. Box 850Hershey, PA 17033-0850, USAE-mail: aundar@psu.eduSearch for more papers by this author First published: 24 November 2010 https://doi.org/10.1111/j.1525-1594.2010.01126.xCitations: 5 Funding for this conference was made possible (in part) by 5 R13 HL096358-02 from the National Institutes of Health, National Heart, Lung and Blood Institute. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume34, Issue11November 2010Pages 865-868 RelatedInformation

International Society for Pediatric Mechanical Cardiopulmonary Support

International Society for Pediatric Mechanical Cardiopulmonary Support

Transport of Critically Ill Children on Cardiopulmonary Support Assistance

Objective: To report two patients helicopter transport on mechanical cardiopulmonary support to a transplant center. Setting: Cardiac intensive care unit (CICU) and transport helicopter. Patients: A 9 kg and 22 kg children who suffer cardiac deterioration needing air transport on mechanical cardiopulmonary support. Interventions and Results: CPS was initiated to support these patients failing cardiac function. Transport on CPS of these two patients to a transplant institution was accomplished after determining that heart transplantation would be their more likely chance for recovery. Conclusion: A cardiac deterioration event that will lead to the need for heart transplantation can be acute and sudden sparing no time for early referral to a transplant center. It is necessary for heart centers to have a plan of action to provide inter-hospital transport on cardiopulmonary support (CPS). This protocol can involve transport by the refer ral institution, the receiving institution or a third institution.

Case report: severe microscopic polyangiitis successfully treated with extracorporeal membrane oxygenation and immunosuppression in a pediatric patient

Severe microscopic polyangiitis can result in acute respiratory failure and renal failure and is commonly treated with mechanical cardiopulmonary support, along with immunosuppression. We report the use of continuous renal replacement therapy and rituximab in a 13-year-old boy with P-antineutrophil cytoplasmic antibody-positive microscopic polyangiitis, resulting in pulmonary hemorrhage and acute renal failure. The patient was treated with high-frequency oscillatory ventilation, extracorporeal membrane oxygenation, and continuous renal replacement therapy, in addition to plasmapheresis, corticosteroids, cyclophosphamide, and rituximab.

Local Anesthetic-Induced Cardiac Toxicity: A Survey of Contemporary Practice Strategies Among Academic Anesthesiology Departments

Though new local anesthetics (LA), effective test-dosing, and new regional anesthetic techniques may have improved the safety of regional anesthesia, the optimal management plan for LA-induced cardiac toxicity remains uncertain. Accordingly, we evaluated current approaches to LA cardiotoxicity among academic anesthesiology departments in the United States. A 19-question survey regarding regional anesthesia practices and approaches to LA cardiac toxicity was sent to the 135 academic anesthesiology departments listed by the Society of Academic Anesthesiology Chairs-Association of Anesthesiology Program Directors. Ninety-one anonymously completed questionnaires were returned, at a response rate of 67%. The respondents were categorized into groups according to the number of peripheral nerve blocks (PNBs) performed each month: >70 PNBs (38%), 51-70 PNBs (13%), 31-50 PNBs (20%), 11-30 PNBs (23%), and <10 PNBs (6%). Anesthesia practices administering >70 PNBs were 1.7-times more likely to use ropivacaine (NS), 3.9-times more likely to consider lipid emulsion infusions for resuscitation (P = 0.008), and equally as likely to have an established plan for use of invasive mechanical cardiopulmonary support in the event of LA cardiotoxicity (NS) than low-PNB volume centers. We conclude that there are differences in the management and preparedness for treatment of LA toxicity among institutions, but the safety implications of these differences are undetermined.

Invited commentary

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

Rapid Cardiopulmonary Support in Children With Heart Disease: A Nine-Year Experience

We 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. All children supported with CPS (110 procedures) were reviewed. Noncardiac CPS cases (7) were excluded. The study population was divided into two time periods (1995 to 2000 and 2001 to 2004), which correlate with significant differences in intraoperative, postoperative, and CPS management. Patients were further analyzed by age (< or = 30 days or > 30 days), repair complexity (risk adjusted classification for congenital heart surgery [RACHS]-1 category 6 or categories 1 to 5), and length of support. Overall thirty day survival of cardiac CPS patients was 55% (57 of 103). Overall survival increased from 45% (23 of 51) during the first period to 65% (34 of 52) during the second period [p < or = 0.005]. Survival rates in neonates improved from 41% (11 of 27) to 56% (15 of 27) and RACHS-1 category 6 survival improved from 38% (5 of 13) to 69% (9 of 13), but neither change reached statistical significance. Intracranial hemorrhage occurred in 6.4% of all CPS patients. Cardiopulmonary support is an effective alternative to ECMO for pediatric cardiac support. Further, our experience suggests that patient survival may be improved by CPS compared with reported results for ECMO in cardiac patients.

Patterns of Lactate Values after Congenital Heart Surgery and Timing of Cardiopulmonary Support

We sought to determine if postoperative serial lactate determinations follow predictable patterns that could be useful in directing management, especially the initiation of postoperative mechanical cardiopulmonary support (CPS). Eight patients undergoing CPS in a 2-year period and 147 patients not requiring postoperative CPS in 6 months of that period were stratified into 6 categories based on short-term risk for mortality (1 being the lowest risk). Lactate values for the first 48 hours postoperatively were retrospectively analyzed. Survivors not requiring CPS in category 6 (n = 16) followed a distinct pattern different from those of categories 1 through 4 (n = 128). Review of postoperative CPS survivors (n = 4) indicated that CPS was initiated electively without cardiac arrest in all 4, and lactate values showed a downward trend within 12 hours of initiation in all cases (mean lactate, 10.12 +/- 1.88 mmol/L; range, 1.4 to 16 mmol/L; mean initiation time, 16.5 hours postoperatively). Three fourths of the CPS nonsurvivors suffered cardiac arrest before CPS and showed rising lactate values despite support (mean lactate, 11.95 +/- 1.37 mmol/L; range, 1.6 to 18.6 mmol/L; mean initiation time, 21.25 hours postoperatively). Indications for initiation of CPS in patients with elevated lactate values were reviewed. Two thirds of patients who died without CPS had preterminal cardiac arrest. We have defined the normal pattern of postoperative lactate values in our institution. These data suggest that an abnormal lactate pattern may be useful in determining the timing of CPS initiation in hemodynamically stable patients with high or rising lactate values, before cardiac arrest or end organ damage.