J Extra Corpor Technol 2025 , 57 , 2 – 8 Ó The Author ( s ), published by EDP Sciences , 2025 https :// doi . org / 10.1051 / ject / 2024038
Available online at : ject . edpsciences . org
ORIGINAL ARTICLE
Pediatric cardiac patients with pulmonary hemorrhage supported on ECMO : An ELSO registry study
Pilar Anton-Martin ( MD , PhD ) 1 ,* , Caroline Young ( MD ) 2 , Hitesh Sandhu ( MD ) 3 , and Shilpa Vellore ( MD ) 4
1 Department of Pediatrics , Division of Anesthesiology and Critical Care Medicine , Children ’ s Hospital of Philadelphia , Philadelphia , PA 19130 , USA 2 Department of Pediatrics , Division of Critical Care , Emory University School of Medicine / Children ’ s Healthcare of Atlanta , Atlanta ,
GA 30329 , USA 3 Department of Pediatrics , Division of Critical Care , University of Tennessee Health Science Center / Le Bonheur Children ’ s Hospital , Memphis , TN 38103 , USA 4 Department of Pediatrics , Division of Cardiology , University of California San Diego School of Medicine / Rady Children ’ s Hospital , San Diego , CA 92123 , USA Received 24 July 2024 , Accepted 25 November 2024
Abstract – Background : Pulmonary Hemorrhage ( PH ) is a rare but potentially devastating condition and pediatric cardiac patients are at increased risk for . ECMO may be used to safely support these patients , but data is limited . Methods : Observational retrospective cohort study from the ELSO registry database in pediatric cardiac patients from birth to 18 years old with PH supported on ECMO from January 2011 through December 2020 . The objectives of the study were to characterize pediatric cardiac patients with PH before ECMO and to describe factors associated with improved survival . Results : A total of 161 cardiac neonates and children with PH supported on ECMO were analyzed . Median age and weight were 40 days ( IQR 7.3 – 452 ) and 4.06 kg ( IQR 3 – 9.36 ), respectively . Congenital heart disease accounted for 77 % of diagnoses . Survival to hospital discharge was 35.8 %. Before ECMO cannulation , most patients were ventilated in conventional modes ( 79.7 %), followed by high-frequency oscillatory ( HFOV ) ventilation ( 11 %). There was a significantly higher use of HFOV pre-cannulation in survivors compared to non-survivors ( 24.4 % vs 2.8 %, p < 0.001 ). Multivariable logistic regression demonstrated that HFOV before ECMO ( OR 28.44 , p < 0.001 ) and the absence of hemorrhagic ( OR 3.51 , p 0.031 ) and renal ( OR 3.50 , p 0.027 ) complications were independent predictors for survival to hospital discharge . Conclusion : Utilization of HFOV before cannulation to ECMO seems to be associated with improved survival in pediatric cardiac patients with acute pulmonary hemorrhage . A prospective assessment of mechanical ventilation practices before ECMO may improve outcomes in this medically complex population .
Key words : ECMO , High-frequency oscillatory ventilation , Children , Heart disease , Survival .
Introduction
Pulmonary Hemorrhage ( PH ) is a rare but potentially devastating condition in neonates and children . Massive bleeding may occur secondary to vascular injury ( infections , immunemediated processes like vasculitides , drug toxicity ), abnormal architecture of the pulmonary vasculature ( either congenital or acquired ), trauma , etc . [ 1 ]. The incidence of massive PH in children is variable depending upon the cause and population reviewed [ 2 ]. In their 10-year review of the causes of hemoptysis at a single large institution , Coss Bu et al . reported that the most frequent causes were cystic fibrosis in 65 %, congenital
* Corresponding author : pilarantonmartin @ gmail . com heart disease ( CHD ) in 16 %, with the remaining 19 % being due to infections , neoplasms , and other causes [ 2 ].
Patients with CHD are at increased risk of PH due to multiple factors [ 3 , 4 ]. However , the true incidence of PH within this subpopulation is particularly difficult to determine due to the paucity of classic PH symptoms [ 3 , 4 ]. While traditionally hemoptysis , pulmonary infiltrates , and anemia are seen in PH , one or multiple of these signs may be absent or not connected to a unified PH diagnosis in pediatric cardiac patients [ 3 , 5 ].
Patients with severe PH have been successfully treated with high-frequency oscillatory ventilation ( HFOV ) [ 6 ]. Additionally , extracorporeal membrane oxygenation ( ECMO ) may be used safely to support pediatric patients with PH , however , outcome data is limited [ 7 – 13 ]. While HFOV may be utilized in
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