Minimizing bleeding associated with mechanical circulatory support following pediatric heart surgery.
OBJECTIVE
The use of extracorporeal membrane oxygenation (ECMO) to support patients with early postcardiotomy heart failure may be associated with catastrophic bleeding, making its use undesirable. However, postcardiotomy mechanical circulatory assistance is necessary in some patients to allow for myocardial recovery. We have assembled a centrifugal pump system (CPS) that does not require early systemic anticoagulation. This study compares postoperative bleeding in pediatric patients placed on standard ECMO versus CPS within 24h of cardiotomy.


METHODS
Between November 2002 and February 2007, 25 patients (age 0 days-1.72 years) received postcardiotomy mechanical support. Fourteen patients were placed on ECMO and 11 patients were placed on CPS within 24h of surgical repair. Retrospective analysis was performed of chest-tube drainage at multiple time points following initiation of mechanical support. Additional variables, including Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) score, total time on mechanical support, 30-day mortality, activated clotting time, blood-product administration, circuit-related complications, and circuit changes were also analyzed.


RESULTS
Patients on ECMO (0.30 ± 0.39 years) and CPS (0.40 ± 0.56 years) were of similar age (p = 0.64). Patients on ECMO (0.3 ± 0.1m(2)) and CPS (0.3 ± 0.1m(2)) had similar body surface areas (p = 0.46). Patients placed on CPS had significantly less chest-tube drainage during the first 4h of support. Activated clotting times appeared to be higher during the first 12h of ECMO versus CPS. There was no statistical difference between ECMO and CPS with respect to the following variables: RACHS-1 score, time on support, 30-day mortality, circuit-related complications, and circuit changes. Blood-product administration at 24h of support was significantly less (p = 0.04) for patients on CPS versus ECMO.


CONCLUSIONS
Mechanical circulatory support can be provided without the complication of clinically significant bleeding if a specialized circuit is used. This has important implications for the decision to use mechanical support in the immediate postoperative period in the face of ventricular failure. In addition, early mechanical support can be used with a low incidence of circuit-related complications.
McMullan
David Michael
DM
Seattle Children's Hospital, Seattle, WA 98105-0371, USA. michael.mcmullan@seattlechildrens.org
Emmert
Jennifer A
JA
Permut
Lester C
LC
Mazor
Robert L
RL
Jeffries
Howard E
HE
Parrish
Andrea R
AR
Baden
Harris P
HP
Cohen
Gordon A
GA
D015505:Chest Tubes; D004322:Drainage; D005112:Extracorporeal Circulation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D006330:Heart Defects, Congenital / Q000601:surgery*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D011182:Postoperative Care / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods; D019106:Postoperative Hemorrhage / Q000209:etiology* / Q000517:prevention & control; D012189:Retrospective Studies; D014914:Whole Blood Coagulation Time