Korean Circ J.  2017 Jul;47(4):490-500. 10.4070/kcj.2016.0320.

Experience with Mechanical Circulatory Support for Medically Intractable Low Cardiac Output in a Pediatric Intensive Care Unit

• Park JB
• Kwak JG
• Lim HG
• Kim WH
• Lee JR
• Kim YJ

• KMID: 2392887
• DOI: http://doi.org/10.4070/kcj.2016.0320

Abstract

BACKGROUND AND OBJECTIVES
Mechanical circulatory support with extracorporeal membrane oxygenation (ECMO) and ventricular assist device has always been the optimal choice for treating the majority of medically intractable low cardiac output case. We retrospectively investigated our institution's outcomes and variables associated with a high risk of mortality.
SUBJECTS AND METHODS
From 1999 to 2014, 86 patients who were of pediatric age or had grown-up congenital heart disease underwent mechanical circulatory support for medically intractable low cardiac output in our pediatric intensive care unit. Of these, 9 grown-up congenital heart disease patients were over 18 years of age, and the median age of the subject group was 5.82 years (range: 1 day to 41.6 years). A review of all demographic, clinical, and surgical data and survival analysis were performed.
RESULTS
A total of 45 (52.3%) patients were successfully weaned from the mechanical assist device, and 25 (29.1%) survivors were able to be discharged. There was no significant difference in results between patients over 18 years and under 18 years of age. Risk factors for mortality were younger age (<30 days), functional single ventricle anatomy, support after cardiac operations, longer support duration, and deteriorated pre-ECMO status (severe metabolic acidosis and increased levels of lactate, creatinine, bilirubin, or liver enzyme). The survival rate has improved since 2010 (from 25% before 2010 to 35% after 2010), when we introduced an upgraded oxygenator, activated heart transplantation, and also began to apply ECMO before the end-stage of cardiac dysfunction, even though we could not reveal significant correlations between survival rate and changed strategies associated with ECMO.
CONCLUSION
Mechanical circulatory support has played a critical role and has had a dramatic effect on survival in patients with medically intractable heart failure, particularly in recent years. Meticulous monitoring of acid-base status, laboratory findings, and early and liberal applications are recommended to improve outcomes without critical complication rates, particularly in neonates with single ventricle physiology.

Keyword

Resuscitation; Low cardiac output; Extracorporeal membrane oxygenation; Ventricular assist device

MeSH Terms

Acidosis
Bilirubin
Cardiac Output, Low*
Creatinine
Critical Care*
Extracorporeal Membrane Oxygenation
Heart Defects, Congenital
Heart Failure
Heart Transplantation
Heart-Assist Devices
Humans
Infant, Newborn
Intensive Care Units*
Lactic Acid
Liver
Mortality
Oxygen
Oxygenators
Physiology
Resuscitation
Retrospective Studies
Risk Factors
Survival Rate
Survivors
Bilirubin
Creatinine
Lactic Acid
Oxygen

Figure

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  Fig. 1 Temporal trend for the annual number of pediatric heart surgeries performed at Seoul National University Children's Hospital.

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  Fig. 2 Flowchart demonstrating the selection of mode of mechanical circulatory assist in the studied patients. The number of patients who were assisted with the device and hospital survival are indicated. ECMO: extracorporeal circulatory membrane oxygenation, VAD: ventricular assisted device, TPL: transplantation, HS: hospital survival.

• 

  Fig. 3 Era effect on survival of patients on mechanical circulatory support. Although improvement in survival rate was not significant (p>0.05), an increasing temporal trend of survival over 16 years was shown.

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