L . Gutiérrez-Soriano et al .: J Extra Corpor Technol 2023 , 55 , 197 – 200 199 etiology of the arrest is thought to be “ amenable to recovery or transplantation ”, according to The American Heart Association ( AHA ) [ 5 ].
A 2016 evaluation of the AHA ’ s get with the Guidelines – Resuscitation registry revealed that for children with in-hospital CPR > 10 min duration , ECPR has been associated with improved survival to hospital discharge and survival with favorable neurologic outcomes [ 6 ]. Despite increased experience with ECMO in adults and children , ideal criteria for pediatric ECPR have not been completely described . This is in part to different factors that affect the outcomes and variations in resources and management strategies in hospitals , for example the availability of resources in different institutions , and the lack of a clear protocol within the institutions to implement these strategies . For that reason , a methodical approach to ECPR implementation and monitoring of long-term outcomes is essential .
Patients with congenital heart disease who are taken to surgery have a higher risk of presenting neurological lesions in the postoperative period ; this risk is higher in procedures using cardiopulmonary bypass [ 7 ]. The actual incidence of neurological complications is difficult to establish and varies in the literature . In neonatal and infant patients , it is difficult to assess neurological compromise due to limitations in functional assessment because of age and apparently due to potential brain plasticity that may only become evident in very longterm follow-up [ 8 , 9 ].
The pediatric population appears to be more vulnerable to postoperative cardiac dysfunction when they undergo definitive repair of congenital heart disease [ 10 ]. The abnormal elevation of myocardial enzymes is associated with worse outcomes in the early and late postoperative periods . This includes the longer time of ventilatory support , prolonged stay in the ICU , and even mortality [ 11 , 12 ]. Tan et al ., in a meta-analysis of 9 randomized controlled clinical trials involving 793 patients under 18 years of age undergoing Cardiac Surgery , describe the cardioprotective effect of ischemic preconditioning during the early postoperative period . Troponin I levels at 6 h and inotropic scores at 4 – 6 h were lower , as were the ventilatory support and the ICU stay [ 13 ].
Higher lactate levels , higher creatinine levels , and prolonged ECMO duration were associated with higher mortality . Early diagnosis and intervention of residual anatomical problems could improve survival . Bleeding and renal failure were the most common complications and the incidence of renal failure may be correlated with longer hypoperfusion duration [ 1 ]. These findings are similar to those reported in a cohort of 67 patients who underwent E-CPR , where a 33.8 % survival to hospital discharge was described ( 24 of 67 patients ). The most frequent complications , reported in the literature , were bleeding ( 26 of 67 ), kidney failure ( 19 of 67 ), and neurological injury ( 14 of 67 ). Although the outcomes are not unfavorable , the complication rates were high , and of these complications , renal failure is associated with high mortality [ 14 ].
Conclusion
Although the criteria for the use of E-CPR in the early postoperative period for correction of congenital heart disease are not well described in the literature , time (< 30 min ) is considered one of the most important long-term neurological outcome factors . The case of ECPR with CPR time > 30 min and a good neurological outcome is reported here , suggesting that factors such as neuroplasticity and ischemic preconditioning could be associated with improved outcomes over time .
Reviewing the institutional experience of high-volume pediatric ECMO centers takes an initial step toward process improvement and more favorable outcomes . While our data adds to the growing literature supporting the use of pediatric ECPR , larger , multicenter studies are required to meaningfully describe the neurologic outcome and functional status of this population ; survival is an essential but insufficient measure [ 6 ].
Acknowledgements . We would like to express our sincere gratitude to the Fundación Cardioinfantil for their support and collaboration in this case report . Without their valuable contributions and resources , this report would not have been possible . Finally , we would like to express our appreciation to all those who have contributed to this report , whether through their support , guidance , or feedback . Their contributions were essential in shaping the content and ensuring the accuracy of the information presented in this case report . This work was financially supported by the Fundación Cardioinfantil – Institute of Cardiology in Bogotá , Colombia .
Conflict of interest The authors declare no conflict of interest .
Funding The authors received no funding to complete this research .
Data availability The research data are available on request from the authors .
Ethics Ethical approval was not required .
Author contributions
Study conception and design : Laura Gutiérrez-Soriano ; case conception and analysis : Pedro Hurtado Peña ; data collection : Laura Gutiérrez-Soriano and German Andres Franco Gruntorad ; analysis and interpretation of results : Laura Soriano , Eduardo Becerra Zapata , and Nicolas Maya Trujillo ; draft manuscript preparation : Eduardo Becerra Zapata and Nicolas Maya Trujillo . All authors reviewed the results and approved the final version of the manuscript .
References
1 . Zheng G , Wei Z , Jia S , et al . ( 2019 ) Extracorporeal cardiopulmonary resuscitation in children after open heart surgery . Artif Organs 43 ( 7 ), 633 – 640 .