title: Elective decompression of the left ventricle in pediatric patients may reduce the duration of venoarterial extracorporeal membrane oxygenation.
abstract: We aimed to determine the effect of elective left heart decompression at the time of initiation of central venoarterial extracorporeal membrane oxygenation (VA ECMO) on VA ECMO duration and clinical outcomes in children in a single tertiary ECMO referral center with a large pediatric population from a national referral center for pediatric cardiac surgery. We studied 51 episodes of VA ECMO in a historical cohort of 49 pediatric patients treated between the years 1990 and 2013 in the Paediatric Intensive Care Unit (PICU) of the Royal Children's Hospital, Melbourne. The cases had a variety of diagnoses including congenital cardiac abnormalities, sepsis, myocarditis, and cardiomyopathy. Left heart decompression as an elective treatment or an emergency intervention for left heart distension was effectively achieved by a number of methods, including left atrial venting, blade atrial septostomy, and left ventricular cannulation. Elective left heart decompression was associated with a reduction in time on ECMO (128 h) when compared with emergency decompression (236 h) (P = 0.013). Subgroup analysis showed that ECMO duration was greatest in noncardiac patients (elective 138 h, emergency 295 h; P = 0.02) and in patients who died despite both emergency decompression and ECMO (elective 133 h, emergency 354 h; P = 0.002). As the emergency cases had a lower pH, a higher PaCO2 , and a lower oxygenation index and were treated with a higher mean airway pressure, positive end-expiratory pressure, and respiratory rate prior to receiving VA ECMO, we undertook multivariate linear regression modeling to show that only PaCO2 and the timing of left heart decompression were associated with ECMO duration. However, elective left heart decompression was not associated with a reduction in length of PICU stay, duration of mechanical ventilation, or duration of oxygen therapy. Elective left heart decompression was not associated with improved ECMO survival or survival to PICU discharge. Elective left heart decompression may reduce ECMO duration and has therefore the potential to reduce ECMO-related complications. A prospective, randomized controlled trial is indicated to study this intervention further.
authors.affiliation: Department of Paediatric Intensive Care, The Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Anaesthetics, Saint Vincent's Hospital, Melbourne, Victoria, Australia.
authors.forename: Douglas F
authors.initials: DF
authors.lastname: Hacking
authors.forename: Derek
authors.initials: D
authors.lastname: Best
authors.forename: Yves
authors.initials: Y
authors.lastname: d'Udekem
authors.forename: Christian P
authors.initials: CP
authors.lastname: Brizard
authors.forename: Igor E
authors.initials: IE
authors.lastname: Konstantinov
authors.forename: Johnny
authors.initials: J
authors.lastname: Millar
authors.forename: Warwick
authors.initials: W
authors.lastname: Butt
mesh_terms: D000367:Age Factors; D019299:Decompression, Surgical / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D017558:Elective Surgical Procedures; D004630:Emergencies; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D006352:Heart Ventricles / Q000503:physiopathology / Q000601:surgery*; D017052:Hospital Mortality; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007902:Length of Stay; D016014:Linear Models; D008297:Male; D015999:Multivariate Analysis; D010102:Oxygen Inhalation Therapy; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D014739:Victoria
keywords: Duration; Extracorporeal membrane oxygenation; Left heart decompression; Pediatrics