Extracorporeal Life Support in Cyanotic Congenital Heart Disease Before Cardiovascular Operation Nicole M. Hunkeler, MD, Charles E. Canter, MD, Ann Donze, RN, and Thomas L. Spray, MD
From July 1666 to March 1661, extracorporeal membrane oxygenation (ECMO) was used in 8 infants (newborn to 16 months old) with unoperated cyanotic congenital heart disease and cardiopulmonary collapse, associated with. hypercyanotic spoils (4 intants), pulmonary hypertensive crises (3) and sepsis (1). Indications for ECMO support were arterial saturations 166% accompanied by hypotension and metabolic acidosis unresponsive to mechankal ventila6011 with 166% oxygen, paralysis and sedation, and pharmacologic support with inotropes or vasodilators, or both. Venoarterial bypass by carotid/jugular cannulation with flow rates of 166 to 646 ml/kg/mln (mean 466) stabilized all patients. Duration of ECMO support ranged from 15 to 646 hours and was associated with transient seizures (1 patient) and renal failure (1). Seven patients underwent palliative (3 patients) or corrective (4) surgical procedures while on ECMO or within 46 hours of decannulation, including 1 patient bridged to double-lung transplantation with a long (646 hours) duration of ECMO. There was 1 operative and 2 late (>l month after decannulation) deaths, for an overall survival rate of 62%. These S survivors all have normal growth and devdopment, and patent neck vessels at the site of cannulation. These early results indicate that ECMO can be effective mechanical support in cardiovascular crises untreatable with maximal conventional medical therapy and can be used as a bridge to successful surgical palliation or repair. (Am J Cardiol 1992;69:766-793)
E
xtracorporeal membrane oxygenation (ECMO) has becomean important therapeutic tool in the treatment of life-threatening respiratory failure in infants.’ Its use in infants with congenital heart diseasebefore repair has been controversial, with isolated reports of success. 2-3The use of ECMO for the treatment of low cardiac output after corrective or palliative surgery for congenital heart disease4-6led us to hypothesize that ECMO may be useful during the preoperative period in cardiopulmonary emergenciesassociated with congenital heart diseaseunresponsiveto traditional medical therapy. Between July 1988 and March 1991, ECMO was used to treat 145 infants and children at our institution. Forty-one patients (28%) had congenital heart disease,and 8 of these (5%) had cyanotic congenital heart diseaseand were placed on ECMO before any surgical intervention. We report here our experience with these 8 patients. METHODS Patient eohork The 8 patients ranged in age from
newborn to 16 months (median 10 days). Anomalies included: tetralogy of Fallot (4 patients), complete transposition of the great arteries (l), mixed supra- and infracardiac total anomalous pulmonary venous return (l), Ebstein’s anomaly of the tricuspid valve (l), and patent ductus arteriosuswith a right-to-left ductal shunt and pulmonary vascular resistance equal to systemic levels (1). Diagnosis was obtained by 2-dimensional echocardiographywith color flow mapping in 7 patients before ECMO therapy. The supracardiac anomalous pulmonary venous return of the left lung was determined before ECMO in the patient with mixed total anomalousvenous return, with infracardiac anomalous drainage of the right lung detectedby angiography after ECMO decannulation. Extracorporeal
membrane
oxygenation
technique:
The ECMO circuit consisted of a 4-inch roller pump servoregulatedby the venous return using a 0.8 m* Sci Med membrane oxygenator (Sci Med Life System, Inc., Minneapolis, MN) and heat exchanger.Activated clotting time was maintained between 200 to 220 seconds with heparin infusion. Venoarterial bypasswas esFrom the Division of Pediatric Cardiology, Edward Mallmckrodt De- tablished with cannulation of the right carotid artery partment of Pediatrics, and Division of Cardiothoracic Surgery, De- and internal jugular vein. partment of Surgery, Washington University School of Medicine, St. ECMO flow was adjusted after cannulation to Louis, Missouri. Manuscript received August 8, 1991;revised manu- achieve arterial saturations 290%. Ventilatory rate, script receivedNovember 25,199 1, and acceptedNovember 30. Addressfor reprints: Charles E. Canter, MD, St. Louis Children’s inspiratory pressure and inspired oxygen concentration were reduced to 10 to 15 breaths/min, >20 mm Harpital, 400 South Kingshighway, St. Louis, Missouri 63110. 790
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 69
MARCH 15, 1992
Hg and 40%, respectively. Inotropic agents and vasodilators were reduced or eliminated. If a patient was to be decannulated from ECMO before surgery, decannulation occurred when the patient had normal blood gases and blood pressure, with flow rates
From July 1666 to March 1661, extracorporeal membrane oxygenation (ECMO) was used in 8 infants (newborn to 16 months old) with unoperated cyanotic congenital heart disease and cardiopulmonary collapse, associated with. hypercyanotic spoils (4 intants), pulmonary hypertensive crises (3) and sepsis (1). Indications for ECMO support were arterial saturations 166% accompanied by hypotension and metabolic acidosis unresponsive to mechankal ventila6011 with 166% oxygen, paralysis and sedation, and pharmacologic support with inotropes or vasodilators, or both. Venoarterial bypass by carotid/jugular cannulation with flow rates of 166 to 646 ml/kg/mln (mean 466) stabilized all patients. Duration of ECMO support ranged from 15 to 646 hours and was associated with transient seizures (1 patient) and renal failure (1). Seven patients underwent palliative (3 patients) or corrective (4) surgical procedures while on ECMO or within 46 hours of decannulation, including 1 patient bridged to double-lung transplantation with a long (646 hours) duration of ECMO. There was 1 operative and 2 late (>l month after decannulation) deaths, for an overall survival rate of 62%. These S survivors all have normal growth and devdopment, and patent neck vessels at the site of cannulation. These early results indicate that ECMO can be effective mechanical support in cardiovascular crises untreatable with maximal conventional medical therapy and can be used as a bridge to successful surgical palliation or repair. (Am J Cardiol 1992;69:766-793)
E
xtracorporeal membrane oxygenation (ECMO) has becomean important therapeutic tool in the treatment of life-threatening respiratory failure in infants.’ Its use in infants with congenital heart diseasebefore repair has been controversial, with isolated reports of success. 2-3The use of ECMO for the treatment of low cardiac output after corrective or palliative surgery for congenital heart disease4-6led us to hypothesize that ECMO may be useful during the preoperative period in cardiopulmonary emergenciesassociated with congenital heart diseaseunresponsiveto traditional medical therapy. Between July 1988 and March 1991, ECMO was used to treat 145 infants and children at our institution. Forty-one patients (28%) had congenital heart disease,and 8 of these (5%) had cyanotic congenital heart diseaseand were placed on ECMO before any surgical intervention. We report here our experience with these 8 patients. METHODS Patient eohork The 8 patients ranged in age from
newborn to 16 months (median 10 days). Anomalies included: tetralogy of Fallot (4 patients), complete transposition of the great arteries (l), mixed supra- and infracardiac total anomalous pulmonary venous return (l), Ebstein’s anomaly of the tricuspid valve (l), and patent ductus arteriosuswith a right-to-left ductal shunt and pulmonary vascular resistance equal to systemic levels (1). Diagnosis was obtained by 2-dimensional echocardiographywith color flow mapping in 7 patients before ECMO therapy. The supracardiac anomalous pulmonary venous return of the left lung was determined before ECMO in the patient with mixed total anomalousvenous return, with infracardiac anomalous drainage of the right lung detectedby angiography after ECMO decannulation. Extracorporeal
membrane
oxygenation
technique:
The ECMO circuit consisted of a 4-inch roller pump servoregulatedby the venous return using a 0.8 m* Sci Med membrane oxygenator (Sci Med Life System, Inc., Minneapolis, MN) and heat exchanger.Activated clotting time was maintained between 200 to 220 seconds with heparin infusion. Venoarterial bypasswas esFrom the Division of Pediatric Cardiology, Edward Mallmckrodt De- tablished with cannulation of the right carotid artery partment of Pediatrics, and Division of Cardiothoracic Surgery, De- and internal jugular vein. partment of Surgery, Washington University School of Medicine, St. ECMO flow was adjusted after cannulation to Louis, Missouri. Manuscript received August 8, 1991;revised manu- achieve arterial saturations 290%. Ventilatory rate, script receivedNovember 25,199 1, and acceptedNovember 30. Addressfor reprints: Charles E. Canter, MD, St. Louis Children’s inspiratory pressure and inspired oxygen concentration were reduced to 10 to 15 breaths/min, >20 mm Harpital, 400 South Kingshighway, St. Louis, Missouri 63110. 790
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 69
MARCH 15, 1992
Hg and 40%, respectively. Inotropic agents and vasodilators were reduced or eliminated. If a patient was to be decannulated from ECMO before surgery, decannulation occurred when the patient had normal blood gases and blood pressure, with flow rates
