Outcome of extracorporeal membrane oxygenation for early primary graft failure after pediatric heart transplantation

Abstract

Objectives: We sought to analyze the indications and outcome of extracorporeal membrane oxygenation (ECMO) for early primary graft failure and determine its impact on long-term graft function and rejection risk.

Background: Early post-operative graft failure requiring ECMO can complicate heart transplantation.

Methods: A retrospective review of all children requiring ECMO in the early period after transplantation from 1990 to 2007 was undertaken.

Results: Twenty-eight (9%) of 310 children who underwent transplantation for cardiomyopathy (n = 5) or congenital heart disease (n = 23) required ECMO support. The total ischemic time was significantly longer for ECMO-rescued recipients compared with our overall transplantation population (276 +/- 86 min vs. 242 +/- 70 min, p < 0.01). The indication for transplantation, for ECMO support, and the timing of cannulation had no impact on survival. Hyperacute rejection was uncommon. Fifteen children were successfully weaned off ECMO and discharged alive (54%). Mean duration of ECMO was 2.8 days for survivors (median 3 days) compared with 4.8 days for nonsurvivors (median 5 days). There was 100% 3-year survival in the ECMO survivor group, with 13 patients (46%) currently alive at a mean follow-up of 8.1 +/- 3.8 years. The graft function was preserved (shortening fraction 36 +/- 7%), despite an increased number of early rejection episodes (1.7 +/- 1.6 vs. 0.7 +/- 1.3, overall transplant population, p < 0.05) and hemodynamically comprising rejection episodes (1.3 +/- 1.9 vs. 0.7 +/- 1.3, overall transplant population, p < 0.05).

Conclusions: Overall survival was 54%, with all patients surviving to at least 3 years after undergoing transplantation. None of the children requiring >4 days of ECMO support survived. Despite an increased number of early and hemodynamically compromising rejections, the long-term graft function is similar to our overall transplantation population.

Figure 1. Duration of Support for ECMO Survivors Versus Nonsurvivors

The extracorporeal membrane oxygenation (ECMO) duration for primary graft failure between ECMO survivors versus nonsurvivors (p < 0.01) is shown.

Figure 2. Total Ischemic Time of ECMO-Rescued Versus All Transplant Recipients

Total ischemic time between extracorporeal membrane oxygenation (ECMO)-rescued recipients compared with our overall transplant population (p < 0.01) is shown. Tx = transplants.

Figure 3. Rejection Episodes for ECMO Survivors Versus All Transplants

Rejection episodes comparing extracorporeal membrane oxygenation (ECMO) survivors with all patients transplanted in our program are shown. Early rejections are defined as rejection episodes during the first year after transplantation, and very early rejection episodes are defined as occurring during the first month after transplantation. Hemodynamic compromising rejections are defined as abnormal hemodynamics documented at catheterization compared with the patient’s previous baseline and dependence on inotropic support. hem compr = hemodynamic compromise.