There is a sort of a quadruple entendre in the title of this post: ECMO still exists; ECMO is needed if you are ‘not yet dead’ and have a chance of surviving; ECMO decreases mortality if you need it; but, unfortunately, using ECMO may sometimes just delay death. I haven’t written about ECMO before on this blog, even though I have been very involved at certain times in my past, the frequency of needing ECMO for neonatal respiratory disease has become vanishingly rare in my practice (I haven’t referred a meconium aspiration for ECMO in 5 years). ECMO for diaphragmatic hernias and for postoperative cardiogenic shock, however, is still sometimes life-saving. I have put together a number of very recent publications.
Tabbutt S, Ghanayem N, Ravishankar C, Sleeper LA, Cooper DS, Frank DU, et al. Risk factors for hospital morbidity and mortality after the Norwood procedure: A report from the Pediatric Heart Network Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg. 2012;144(4):882-95. Not surprisingly, if you need ECMO after a Norwood, then you are more likely to die. Of those in this large multicenter cohort of infants with hypoplastic left heart syndrome (n=nearly 600) who had post-op ECMO the transplant free survival at 12 months was only 26% compared to 75% if you didn’t need ECMO (and didn’t get CPR either). Still 26% compared to zer0… I guess it depends on your viewpoint, and your resources.
Another study in a similar vein (or should I say with a similar heart) is an analysis of ELSO registry data of over 700 babies who had a Norwood and then needed ECMO. The survival overall (to hospital discharge) was 31%. Sherwin ED, Gauvreau K, Scheurer MA, Rycus PT, Salvin JW, Almodovar MC, et al. Extracorporeal membrane oxygenation after stage 1 palliation for hypoplastic left heart syndrome. The Journal of Thoracic and Cardiovascular Surgery. 2012;144(6):1337-43. The authors note that complications of ECMO are a bad risk factor. The median duration of ECMO among survivors was very close to 72 hours. They show that there was an increased duration of ECMO among non-survivors, and that the Odds Ratio for mortality for every additional day of ECMO is 1.2. Useful information for counselling parents. They also note that there were 28 babies who went back on ECMO for a second time, after the first decannulation, only 1 survived. Probably if you re-satisfy criteria to go back on ECMO, unless there is a surgically correctable reason, you should not offer a second course of ECMO.
But what if you have congenital heart disease and a diaphragmatic hernia? Is ECMO a reasonable option? Dyamenahalli U, Morris M, Rycus P, Bhutta AT, Tweddell JS, Prodhan P. Short-Term Outcome of Neonates With Congenital Heart Disease and Diaphragmatic Hernia Treated With Extracorporeal Membrane Oxygenation. The Annals of Thoracic Surgery. 2013;95(4):1373-6 This report from the ELSO registry has surprisingly good outcomes, and some surprises in the results. For infants with a diaphragmatic hernia who needed ECMO, survival to hospital discharge for those who also had hypoplastic left heart syndrome and single-ventricle physiology was 55% (33 of 60), 48% (43 of 89) for ventricular septal defect, and 40% (24 of 60) for coarctation of the aorta patients. Which is a little weird, infants who had the most severe heart disease had better survival than those with less severe heart disease. I can think of a couple of possible reasons for this. But if you need ECMO for your diaphragmatic hernia (CDH) a VSD is probably not very relevant; it just means that you have a really bad CDH. Whereas if you have a hypoplastic left heart, it is much easier to satisfy ECMO criteria, so you might have less pulmonary hypoplasia, and a better prognosis for short term survival. How you might do after the second stage of the hypoplastic left heart repair is not clear.
Madderom MJ, Toussaint L, van der Cammen-van Zijp MHM, Gischler SJ, Wijnen RMH, Tibboel D, et al. Congenital diaphragmatic hernia with(out) ECMO: impaired development at 8 years. Archives of Disease in Childhood – Fetal and Neonatal Edition. 2012. This study was a very complete evaluation of 8 year old survivors of CDH repair. The children who needed ECMO in the neonatal period had lower IQ scores than those who survived without. Dutch children are obviously very intelligent, the CDH children who did not need ECMO had a mean IQ of 112. It must be all that cheese or more likely the raw herring ‘Hollandse nieuwe haring’, yum yum. Or maybe living below sea level with their higher PaO2 helps brain development, it certainly makes them tall. The CDH children who had needed ECMO didn’t do quite as well (mean IQ 91) and both groups had troubles with concentration, but overall their quality of life was really good.
If we look at the ELSO registry data for acute neurologic complications (Polito A, Barrett CS, Wypij D, Rycus PT, Netto R, Cogo PE, et al. Neurologic complications in neonates supported with extracorporeal membrane oxygenation. An analysis of ELSO registry data. Intensive care medicine. 2013:1-8) we find that they are common, occurring in about 20% of supported infants, and associated with increased mortality. As always in database information, we don’t know if that might be because the medical care changed as a result of the complication. Is the increased mortality because care was redirected after a complication?…
Madderom MJ, Reuser JJ, Utens EM, van Rosmalen J, Raets M, Govaert P, et al. Neurodevelopmental, educational and behavioral outcome at 8 years after neonatal ECMO: a nationwide multicenter study. Intensive care medicine. 2013:1-10. 135 Dutch babies required ECMO in a 5 year period. Eight years later the survivors are doing really well. The mean IQ is 100 ( I know for a Dutch child that is probably rather low, but it still sounds quite good for the rest of the world). They did have some problems, with some attention difficulties, and a few more having learning disability that will probably require specific educational attention. But these outcomes are very encouraging, and in addition, they aren’t dead yet!