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Cardiac extracorporeal life support: state of the art in 2007

Published online by Cambridge University Press:  26 November 2007

David S. Cooper ,
Jeffrey P. Jacobs ,
Lisa Moore ,
Arabela Stock ,
J. William Gaynor ,
Thomas Chancy ,
Michael Parpard ,
Dee Ann Griffin ,
Tami Owens  and
Paul A. Checchia
...Show all authors
David S. Cooper*
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
Jeffrey P. Jacobs
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
Lisa Moore
Affiliation:
Advance Medical Therapies Coordinator, All Children’s Hospital, Saint Petersburg, Florida, United States of America
Arabela Stock
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
J. William Gaynor
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
Thomas Chancy
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
Michael Parpard
Affiliation:
The Congenital Heart Institute of Florida, Divisions of Critical Care and Thoracic and Cardiovascular Surgery, All Children’s Hospital/Children’s Hospital of Tampa, University of South Florida College of Medicine, Florida Pediatric Associates and Cardiac Surgical Associates, Saint Petersburg and Tampa, Florida, United States of America
Dee Ann Griffin
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
Tami Owens
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
Paul A. Checchia
Affiliation:
St. Louis Children’s Hospital, Washington University School of Medicine, Missouri, United States of America
Ravi R. Thiagarajan
Affiliation:
Children’s Hospital Boston, Harvard Medical School, Massachusetts, United States of America
Thomas L. Spray
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
Chitra Ravishankar
Affiliation:
The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, United States of America
*
Correspondence to: David S. Cooper, MD, MPH, The Congenital Heart Institute of Florida (CHIF), Clinical Assistant Professor of Pediatrics, University of South Florida, Florida Pediatric Associates, 880 Sixth Street South, Suite 370, St. Petersburg, FL 33701, USA. Tel: +727 767 4375; E-mail: davidscooper@verizon.net
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Abstract

Mechanical circulatory support is an invaluable tool in the care of children with severe refractory cardiac and or pulmonary failure. Two forms of mechanical circulatory support are currently available to neonates, infants, and smaller children, namely extracorporeal membrane oxygenation and use of a ventricular assist device, with each technique having unique advantages and disadvantages. The intra-aortic balloon pump is a third form of mechanical support that has been successfully used in larger children, adolescents, and adults, but has limited applicability in smaller children. In this review, we discuss the current experiences with extracorporeal membrane oxygenation and ventricular assist devices in children with cardiac disease.

A variety of forms of mechanical circulatory support are available for children with cardiopulmonary dysfunction refractory to conventional management. These devices require extensive resources, both human and economic. Extracorporeal membrane oxygenation can be effectively used in a variety of settings to provide support to critically-ill patients with cardiac disease. Careful selection of patients and timing of intervention remains challenging. Special consideration should be given to children with cardiac disease with regard to anatomy, physiology, cannulation, and circuit management. Even though exciting progress is being made in the development of ventricular assist devices for long-term mechanical support in children, extracorporeal membrane oxygenation remains the mainstay of mechanical circulatory support in children with complex anatomy, particularly those needing rapid resuscitation and those with a functionally univentricular circulation.

As the familiarity and experience with extracorporeal membrane oxygenation has grown, new indications have evolved, including emergent resuscitation. This utilization has been termed extracorporeal cardiopulmonary resuscitation. The literature supporting emergent cardiopulmonary support is mounting. Reasonable survival rates have been achieved after initiation of support during active compressions of the chest following in-hospital cardiac arrest. Due to the limitations of conventional circuits for extracorporeal membrane oxygenation, some centres have developed novel systems for rapid cardiopulmonary support.

Many centres previously considered a functionally univentricular circulation to be a contraindication to extracorporeal membrane oxygenation, but improved results have been achieved recently with this complex subset of patients. The registry of the Extracorporeal Life Support Organization recently reported the outcome of extracorporeal life support used in neonates for cardiac indications from 1996 to 2000. Of the 740 neonates who were placed on extracorporeal life support for cardiac indications, 118 had hypoplastic left heart syndrome. There was no significant difference in survival between these patients and those with other defects. It is now common to use extracorporeal membrane oxygenation to support patients with a functionally univentricular circulation, and reasonable survival rates are to be expected.

Although extracorporeal membrane oxygenation has become a standard of care for many paediatric centres, its use is limited to those patients who require only short-term cardiopulmonary support. Mechanical ventricular assist devices have become standard therapy for adults with cardiac failure refractory to maximal medical management. Several devices are readily available in the United States of America for adults, but there are fewer options available to children. Over the last few years, substantial progress has been made in paediatric mechanical support. Ventricular assist devices are being used with increasing frequency in children with cardiac failure refractory to medical therapy for primary treatment as a long-term bridge to recovery or transplantation. The paracorporeal, pneumatic, pulsatile “Berlin Heart” ventricular assist device is being used with increasing frequency in Europe and North America to provide univentricular and biventricular support. With this device, a patient can be maintained on mechanical circulatory support while extubated, being mobilized, and feeding by mouth.

Mechanical circulatory support should be anticipated, and every attempt must be made to initiate support “urgently” rather than “emergently”, before the presence of dysfunction of end organs or circulatory collapse. In an emergency, these patients can be resuscitated with extracorporeal membrane oxygenation and subsequently transitioned to a long-term ventricular assist device after a period of stability.

Keywords

Extracorporeal membrane oxygenationventricular assist devicelow cardiac output syndromecardiogenic shockcardiopulmonary resuscitation
Type
Original Article
Information
Cardiology in the Young , Volume 17 , Supplement S4 , September 2007 , pp. 104 - 115
Copyright
Copyright © Cambridge University Press 2007

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