Extracorporeal Cardiopulmonary Resuscitation Use Among Children With Cardiac Disease in the ICU: A Meta-Analysis and Meta-Regression of Data Through March 2024

Abstract

Objective: Epidemiologic data on extracorporeal cardiopulmonary resuscitation (ECPR) use in children with cardiac disease after in-hospital cardiac arrest (IHCA) are lacking. We aimed to investigate trends in ECPR use over time in critically ill children with cardiac disease.

Data sources: We performed a secondary analysis of a recent systematic review (PROSPERO CRD42020156247) to investigate trends in ECPR use in children with cardiac disease. PubMed, Web of Science, Embase, and Cumulative Index to Nursing and Allied Health Literature were screened (inception to September 2021). For completeness of this secondary analysis, PubMed was also rescreened (September 2021 to March 2024).

Study selection: Observational studies including epidemiologic data on ECPR use in children with cardiac disease admitted to an ICU.

Data extraction: Data were extracted by two independent investigators. The risk of bias was assessed using the National Heart Lung and Blood Institutes Quality Assessment Tools. Random-effects meta-analysis was used to compute a pooled proportion of subjects undergoing ECPR; meta-regression was used to assess trends in ECPR use over time.

Data synthesis: Of the 2664 studies identified, 9 (17,669 patients) included data on ECPR use in children with cardiac disease. Eight were cohort studies, 1 was a case-control, 8 were retrospective, 1 was prospective, 6 were single-center, and 3 were multicenter. Seven studies were included in the meta-analysis; all were judged of good quality. By meta-analysis, we found that a pooled proportion of 21% (95% CI, 15-29%) of pediatric patients with cardiac disease experiencing IHCA were supported with ECPR. By meta-regression adjusted for category of patients (surgical vs. general cardiac), we found that the use of ECPR in critically ill children with cardiac disease significantly increased over time ( p = 0 .026).

Conclusions: About one-fifth of critically ill pediatric cardiac patients experiencing IHCA were supported with ECPR, and its use significantly increased over time. This may partially explain the increased trends in survival demonstrated for this population.

Figure 1.

PRISMA Flow chart of the study selection process.

Figure 2.. Pooled proportion of pediatric ICU patients with cardiac disease undergoing ECPR by random effects meta-analysis.

In centers with ECMO expertise, ECPR was used in a pooled proportion of 21% (95%CI 15–29%) of patients. The pooled proportion was calculated by random-effects meta-analysis using a logit transformation and a generalized linear mixed effects modeling method. Publication bias was assessed using the funnel plot method.

Figure 3.. Trend in use of ECPR over time by meta-regression.

The proportion of ECPR use after in-hospital cardiac arrest in pediatric ICU patients with cardiac disease significantly increased in the last two decades (p=0.026). The model was adjusted for category of patients (surgical vs general cardiac). The mid recruitment year was used as a measure of time. The same analysis was performed, and results were confirmed, using the last-recruitment year as a measure of time (Supplemental Figure 1).