4 P . Anton-Martin et al .: J Extra Corpor Technol 2025 , 57 , 2 – 8
Figure 1 . Distribution of cardiac patients with pulmonary hemorrhage supported on ECMO over time .
compared to non-survivors ( 24.4 % vs 2.8 %, p < 0.001 ). Non-survivors significantly had more arrests before ECMO than survivors ( 45.1 % vs 29.3 %, p 0.044 ). No differences were observed in ECMO mode and type , cannulation location , and cardiac index provided for support . Survivors had significantly longer LOS and MV duration than non-survivors ( 43.5 vs 23 days , p < 0.001 and 387 vs 315 h , p 0.01 ; respectively ) likely due to early deaths in the latter . Non-survivors had significantly more cardiovascular , hemorrhagic , mechanical , metabolic , neurologic , respiratory , and renal complications ( Table 1 ).
Factors associated with survival to hospital discharge
Multivariable logistic regression models were used to evaluate factors associated with survival to hospital discharge . After adjusting for confounders , HFOV before ECMO cannulation was an independent predictor for survival to hospital discharge ( OR 28.44 , p < 0.001 ). Other predictors of survival were the absence of hemorrhagic ( OR 3.51 , p 0.031 ) and renal ( OR 3.50 , p 0.027 ) complications during ECMO support . Table 3 summarizes the logistic regression analysis final model after backward selection .
Discussion
This study is the first to date to uniquely characterize predictors of survival to hospital discharge in pediatric cardiac patients with PH requiring ECMO . In our study , HFOV before ECMO cannulation was an independent predictor for improved survival to hospital discharge in this cohort . The absence of renal and hemorrhagic complications were also independent predictors of survival in this population . This finding is supported by prior research that examined the impact of ECMO complications on patient mortality [ 15 , 16 ].
Pediatric patients with heart disease are at heightened risk for acute PH due to several physiologic factors inherent to their disease process such as increased pulmonary pressures associated with a systemic to pulmonary shunt or elevated downstream pressures ( such as left atrial hypertension ), formation of arteriovenous malformations , development of veno-occlusive disease or association with bronchopulmonary abnormalities , etc . [ 3 , 4 ]. Genetic abnormalities ( such as Trisomy 21 ) commonly associated with CHD also independently place these patients at increased risk for PH [ 17 , 18 ]. Furthermore , while traditionally hemoptysis , pulmonary infiltrates , and anemia are seen in patients with PH , these are often non-existent or attributed to other causes in infants and children with CHD complicating an early PH diagnosis [ 3 , 5 ].
HFOV offers the theoretical benefit of minimizing ventilator-associated lung injury but data supporting positive outcomes have varied in previous research [ 19 ]. When employed in patients with acute PH , HFOV offers the advantage of high mean airway pressures that could help tamponade ongoing bleeding [ 14 ]. HFOV however is traditionally used with hesitancy in pediatric patients with heart disease due to the potential effects of increased intrathoracic pressure in reducing pulmonary venous return and / or increasing right ventricular afterload , thereby decreasing overall cardiac output [ 14 ]. However , some studies did not demonstrate hemodynamic deterioration using HFOV in non-operated and postoperative pediatric heart disease patients [ 14 , 20 ]. Our study indicates that the use of HFOV in pediatric patients with heart disease and acute PH is a feasible option that may have contributed to improvement in survival . This may be attributable to the control of alveolar hemorrhage and subsequent improvement in lung compliance and gas exchange leading to better outcomes . Patients in the HFOV group were likely predisposed to respiratory conditions with severe oxygenation deficits . Variations in disease characteristics and comorbidities between ventilation groups , not captured by the ELSO registry , may have also influenced differences in survival . The use of ECMO for severe respiratory failure due to PH was historically discouraged given the need for systemic anticoagulation . However , several pediatric case studies have demonstrated that ECMO is feasible to manage life-threatening PH refractory to conventional therapy and allows time for diagnosis-directed therapies [ 7 – 13 ]. The observed survival benefit identified in this study and the paucity of prior research examining this association proffers an excellent opportunity to prospectively evaluate ventilatory strategies in pediatric cardiac patients with PH before ECMO cannulation .