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Multicenter Study
. 2015 Nov;100(5):1751-7.
doi: 10.1016/j.athoracsur.2015.06.020. Epub 2015 Aug 20.

Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation

David K Werho  1 , Sara K Pasquali  2 , Sunkyung Yu  2 , Janet Donohue  2 , Gail M Annich  3 , Ravi R Thiagarajan  4 , Jennifer C Hirsch-Romano  2 , Michael Gaies  2 ; ELSO Member Centers
Affiliations
Multicenter Study

Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation

David K Werho et al. Ann Thorac Surg. 2015 Nov.

Abstract

Background: Stroke is a common complication of extracorporeal membrane oxygenation (ECMO), and pediatric cardiac surgical patients may be at higher risk. Epidemiology and risk factors for stroke in these patients are not well characterized.

Methods: We analyzed pediatric (<18 years) cardiac ECMO cases in the Extracorporeal Life Support Organization Registry from 2002 to 2013. Cardiac surgical patients were identified, and procedures were stratified according to The Society of Thoracic Surgeons morbidity categories. The primary outcome was any stroke (hemorrhagic or infarction) identified by neuroimaging. Risk factors were identified through multivariable logistic regression.

Results: We analyzed 3,517 cardiac surgical patients; 81% with cyanotic disease, and 57% in high-risk categories from The Society of Thoracic Surgeons (categories 4 and 5). Overall, 12% experienced stroke while receiving ECMO, and those with stroke had greater in-hospital mortality (72% versus 51%; p < 0.0001). In multivariable analysis, neonatal status (adjusted odds ratio, 1.8; 95% confidence interval, 1.3 to 2.4), lower weight-for-age z score (adjusted odds ratio, 1.1 for each 1-point decrease; 95% confidence interval, 1.04 to 1.25), and longer ECMO duration (upper quartile [≥ 167 hours] adjusted odds ratio, 1.4; 95% confidence interval, 1.1 to 1.8) were independently associated with increased stroke risk, whereas cyanotic disease, The Society of Thoracic Surgeons category, and bypass time were not.

Conclusions: This multicenter analysis demonstrates that pediatric cardiac surgical patients on ECMO are at high risk of stroke; younger or underweight patients and those with longer ECMO duration are at greatest risk, independent of procedural complexity. Future study is necessary to determine how anticoagulation or other clinical practices can be modified to reduce stroke incidence.

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Figures

Figure 1
Figure 1
Mortality in cardiac surgical ECMO patients with and without stroke. Values are expressed as the percentage of patients with and without stroke who experienced mortality at the conclusion of ECMO and during their ECMO hospitalization (both p<0.0001). Dark bars represent patients with stroke (n=434), white bars represent patients without stroke (n=3,083).
Figure 2
Figure 2
ECMO duration in patients with and without stroke. The middle line represents the median ECMO duration in each group; the bottom and top of the box represent the 25th and 75th percentiles, respectively; the whiskers represent the 1st and 99th percentiles. Scattered points represent outliers. The dotted line represents the 75th percentile for ECMO duration in the entire cohort (167 hours).
Figure 3
Figure 3
Factors associated with stroke in pediatric cardiac surgical patients on ECMO. The circle represents the adjusted odds ratio of each risk factor by multivariate analysis (closed circles are statistically significant, p<0.05); the whiskers represent the 95% confidence interval. CPB, Cardiopulmonary Bypass; STS, Society of Thoracic Surgeons.
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