Pediatric Cardiology

, Volume 40, Issue 1, pp 89–100 | Cite as

Prognostic Risk Analyses for Postcardiotomy Extracorporeal Membrane Oxygenation in Children: A Review of Early and Intermediate Outcomes

  • Miki AsanoEmail author
  • Hidekazu Matsumae
  • Kazutaka Suzuki
  • Yousuke Nakai
  • Takuya Nakayama
  • Norikazu Nomura
  • Akira Mishima
Original Article


We evaluated the morbidity and mortality of children requiring postcardiotomy extracorporeal membrane oxygenation (ECMO) to determine independent factors affecting early and intermediate outcomes. Between January 2002 and December 2015, 79 instances of ECMO after cardiac surgery in 73 children were retrospectively reviewed. Follow-up was completed in December 2016. Predictive risk analyses were employed concerning weaning of ECMO, hospital discharge, and mortality after discharge. Age and weight were 14.9 ± 25.6 months and 7.0 ± 5.3 kg, respectively. Median support time was 8.3 ± 4.4 days. Sixty-seven (85%) were successfully weaned off ECMO and 48 (61%) survived to hospital discharge. Multi-variate logistic regression analysis identified the first day to obtain negative fluid balance after initiation of support (adjusted odds ratio = 0.42), high serum lactate levels (0.97), and high total bilirubin (0.84) during support as significant independent factors associated with successful separation from ECMO. The first day of negative fluid balance (0.65) after successful decannulation was an independent risk factor for survival to hospital discharge. After hospital discharge, actuarial 1-year, 5-year, and 10-year survival rates were 94%, 78%, and 78%, respectively. Low weight increased the risk of death after hospital discharge by a multi-variate Cox hazard model. High serum lactate, high serum bilirubin, and unable to obtain early negative fluid balance during support impacted mortality of decannulation. Obtaining a late negative fluid balance in post-ECMO were independent risk factors for death after successful weaning. Low weight affected intermediate outcomes.


Extracorporeal membrane oxygenation Fluid negative balance Low body weight Pediatric cardiac surgery Serum bilirubin Serum lactate 


Compliance with Ethical Standards

Conflict of interest

There is no conflict of interest to be disclosed.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informal Consent

For this type of study formal consent is not required.


  1. 1.
    Ravishankar C, Dominguez TE, Kreutzer J, Wernovsky G, Marino BS, Godinez R et al (2006) Extracorporeal membrane oxygenation after stage I reconstruction for hypoplastic left heart syndrome. Pediatr Crit Care Med 7:319–323CrossRefGoogle Scholar
  2. 2.
    Bhat P, Hirsch JC, Gelehrter S, Cooley E, Donohue J, King K et al (2013) Outcomes of infants weighing three kilograms or less requiring extracorporeal membrane oxygenation after cardiac surgery. Ann Thorac Surg 95:656–662CrossRefGoogle Scholar
  3. 3.
    Haines NM, Rycus PT, Zwischenberger JB, Bartlett RH, Undar A (2009) Extracorporeal life support registry report 2008: neonatal and pediatric cardiac cases. ASAIO J 55:111–116CrossRefGoogle Scholar
  4. 4.
    Thiagarajan RR, Barbaro RP, Rycus PT, Mcmullan M, Conrad SA, Fortenberry JD et al (2017) Extracorporeal organization registry international report 2016. ASAIO J 63:60–67CrossRefGoogle Scholar
  5. 5.
    Alsoufi B, Shen I, Karamlou T, Giacomuzzi C, Burch G, Silberbach M et al (2005) Extracorporeal life support in neonates, infants, and children after repair of congenital heart disease: modern era results in a single institution. Ann Thorac Surg 80:15–21CrossRefGoogle Scholar
  6. 6.
    Kolovos NS, Bratton SL, Moler FW, Bove EL, Ohye RG, Bartlett RH et al (2003) Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery. Ann Thorac Surg 76:1435–1442CrossRefGoogle Scholar
  7. 7.
    Baslaim G, Bashore J, Al-Malki F, Jamjoom A (2006) Can the outcome of pediatric extracorporeal membrane oxygenation after cardiac surgery be predicted? Ann Thorac Cardiovasc Surg 12:21–27Google Scholar
  8. 8.
    Aharon AS, Drinkwater DC Jr, Churchwell KB, Quisling SV, Reddy VS, Taylor M et al (2001) Extracorporeal membrane oxygenation in children after repair of congenital cardiac lesions. Ann Thorac Surg 72:2095–2102CrossRefGoogle Scholar
  9. 9.
    Alsoufi B, Al-Radi OO, Gruenwald C, Lean L, Williams WG, McCrindle BW et al (2009) Extra-corporeal life support following cardiac surgery in children: analysis of risk factors and survival in a single institution. Eur J Cardiothorac Surg 35:1004–1011CrossRefGoogle Scholar
  10. 10.
    Polimenakos AC, Wojtyla P, Smith PJ, Rizzo V, Nater M, El Zein CF et al (2011) Post-cardiotomy extracorporeal cardiopulmonary resuscitation in neonates with complex single ventricle: analysis of outcomes. Eur J Cardiothorac Surg 40:1396–1405Google Scholar
  11. 11.
    Kumar TKS, Zurakowski D, Dalton H, Talwar S, Allard-Picou A, Duebener LF et al (2010) Extracorporeal membrane oxygenation in postcardiotomy patients: factors influencing outcome. J Thorac Cardiovasc Surg 140:330–336CrossRefGoogle Scholar
  12. 12.
    Kelly RB, Harrison RE (2010) Outcome predictors of pediatric extracorporeal cardiopulmonary resuscitation. Pediatr Cardiol 31:626–633CrossRefGoogle Scholar
  13. 13.
    Chang WW, Tsai FC, Tsai TY, Chang CH, Jenq CC, Chang MY et al (2012) Predictors of mortality in patients successfully weaned from extracorporeal membrane oxygenation. PLoS ONE 7:e42687CrossRefGoogle Scholar
  14. 14.
    Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M et al (2016) The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 315:801–810CrossRefGoogle Scholar
  15. 15.
    Allan CK, Thiagarajan RR, del Nido PJ, Roth SJ, Almodovar MC, Laussen PC (2007) Indication for initiation of mechanical circulatory support impacts survival of infants with shunted single-ventricle circulation supported with extracorporeal membrane oxygenation. J Thorac Cardiovasc Surg 133:660–667CrossRefGoogle Scholar
  16. 16.
    Sasson L, Cohen I, Tamir A, Sternfeld AR, Berlowitz Y, Lenczner O et al (2013) Extracorporeal membrane oxygenation in pediatric patients: our experience in the last ten years. IMAJ 15:13–16Google Scholar
  17. 17.
    Gelehrter S, Fifer CG, Armstrong A, Hirsch J, Gajarski R (2011) Outcomes of hypoplastic left heart syndrome in low-birth- weight infants. Pediatr Cardiol 32:1175–1181CrossRefGoogle Scholar
  18. 18.
    Alsoufi B, Manlhiot C, Mahle WT, Kogon B, Border WL, Cuadrado A et al (2014) Low-weight infants are at increased mortality risk after palliative or corrective cardiac surgery. J Thorac Cardiovasc Surg 148:2508–2514CrossRefGoogle Scholar
  19. 19.
    Ford MA, Gauvreau K, McMullan DM, Almodovar MC, Cooper DS, Rycus PT et al (2016) Factors associated with mortality in neonates requiring extracorporeal membrane oxygenation for cardiac indications: analysis of the Extracorporeal Life Support Organization Registry data. Pediatr Crit Care Med 17:860–870CrossRefGoogle Scholar
  20. 20.
    Kulik TJ, Moler FW, Palmisano JM, Custer JR, Mosca RS, Bove EL et al (1996) Outcome-associated factors in pediatric patients treated with extracorporeal membrane oxygenator after cardiac surgery. Circulation 94(9 Suppl):II63–II68Google Scholar
  21. 21.
    Salvin JW, Laussen PC, Thiagarajan RR (2008) Extracorporeal membrane oxygenation for postcardiotomy mechanical cardiovascular support in children with congenital heart disease. Pediatr Anesth 18:1157–1162Google Scholar
  22. 22.
    Gajarski RJ, Mosca RS, Ohye RG, Bove EL, Crowley DC, Custer JR et al (2003) Use of extracorporeal life support as a bridge to pediatric cardiac transplantation. J Heart Lung Transplant 22:28–34CrossRefGoogle Scholar
  23. 23.
    Alsoufi B, McCracken C, Schlosser B, Sachdeva R, Well A, Kogon B (2016) Outcomes of multistage palliation of infants with functional single ventricle and heterotaxy syndrome. J Thorac Cardiovasc Surg 151:1369–1377CrossRefGoogle Scholar
  24. 24.
    Balasubramanian SK, Tiruvoipati R, Amin M, Aabideen KK, Peek GJ, Sosnowski AW et al (2007) Factors influencing the outcome of pediatric cardiac surgical patients during extracorporeal circulatory support. J Cardiothorac Surg 2:4–12CrossRefGoogle Scholar
  25. 25.
    Montgomery VL, Strotman JM, Ross MP (2000) Impact of multiple organ system dysfunction and nosicomial infections on survival of children treated with extracorporeal membrane oxygenation after heart surgery. Crit Care Med 28:526–531CrossRefGoogle Scholar
  26. 26.
    Kocis K (2000) Pediatric cardiac extracorporeal membrane oxygenation: supporting life or prolonging death? Crit Care Med 28:594–595CrossRefGoogle Scholar
  27. 27.
    Darling EM, Kaemmer D, Lawson DS, Jaggers JJ, Ungerleider RM (2001) Use of ECMO without the oxygenator to provide ventricular support after Norwood stage I procedures. Ann Thorac Surg 71:735–736CrossRefGoogle Scholar
  28. 28.
    Rousse N, Juthier F, Pinçon C, Hysi I, Banfi C, Robin E et al (2015) ECMO as a bridge to decision: recovery, VAD, or heart transplantation? Int J Cardiol 187:620–627CrossRefGoogle Scholar
  29. 29.
    Jaggers JJ, Forbess JM, Shah AS, Meliones JN, Kirshbom PM, Miller CE et al (2000) Extracorporeal membrane oxygenation for infant postcardiotomy support: significance of shunt management. Ann Thorac Surg 69:1476–1483CrossRefGoogle Scholar
  30. 30.
    Marik PE, Baram M, Vahid B (2008) Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 134:172–178CrossRefGoogle Scholar
  31. 31.
    Bellomo R, Auriemma S, Fabbri A, D’Onofrio A, Katz N, McCullough PA et al (2008) The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI). Int J Artif Organs 31:166–178CrossRefGoogle Scholar
  32. 32.
    Wilder NS, Yu S, Donohue JE, Goldberg CS, Blatt NB (2016) Fluid overload is associated with late poor outcomes in neonates following cardiac surgery. Pediatr Crit Care Med 17:420–427CrossRefGoogle Scholar
  33. 33.
    Hazle MA, Gajarski RJ, Yu S, Donohue J, Blatt NB (2013) Fluid overload in infants following congenital heart surgery. Pediatr Crit Care Med 14:44–49CrossRefGoogle Scholar
  34. 34.
    Thangappan K, Cavarocchi NC, Baram M, Thoma B, Hirose H (2016) Systemic inflammatory response syndrome (SIRS) after extracorporeal membrane oxygenation (ECMO): incidence, risks and survivals. Heart Lung 45:449–453CrossRefGoogle Scholar
  35. 35.
    Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF (2016) The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care 20:387–396CrossRefGoogle Scholar
  36. 36.
    McILwain RB, Timpa JG, Kurundkar AR, Holt DW, Kelly DR, Hartman YE et al (2010) Plasma concentrations of inflammatory cytokines rise rapidly during ECMO-related SIRS due to the release of preformed stores in the intestine. Lab Invest 90:128–139CrossRefGoogle Scholar
  37. 37.
    Punjabi PP, Taylor KM (2013) The science and practice of cardiopulmonary bypass: from cross circulation to ECMO and SIRS. Glob Cardiol Sci Pract 3:249–260Google Scholar
  38. 38.
    Sasser WC, Robert SM, Askenazi DJ, O’Meara LC, Borasino S, Alten JA (2014) Peritoneal dialysis: an alternative modality of fluid removal in neonates requiring extracorporeal membrane oxygenation after cardiac surgery. JECT 46:157–161Google Scholar
  39. 39.
    Salvin JW, Scheurer MA, Laussen PC, Wypij D, Polito A, Bacha EA et al (2011) Blood transfusion after pediatric cardiac surgery is associated with prolonged hospital stay. Ann Thorac Surg 91:204–211CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Faculty of Health Promotional SciencesTokoha UniversityHamamatsuJapan
  2. 2.Department of Cardiovascular SurgeryNagoya City UniversityNagoyaJapan
  3. 3.Department of PediatricsNagoya City UniversityNagoyaJapan
  4. 4.Division of Cardiovascular SurgeryNagoya Kyouritsu HospitalNagoyaJapan

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