2004 OPEN FORUM Abstracts
Safe Utilization of Extra-Corporeal Membrane Oxygenation during Cardiac Catheterization in Patients with Heart Disease
Halwick
DR, Bullock K, Laussen PC Children’s
Hospital Boston & Harvard Medical School Boston, MA
Introduction:
Cardiac Catheterization (CC) is an important diagnostic and
interventional tool in the diagnosis and treatment of pediatric
patients with cardiac disease. An Extra-Corporeal Life Support
program (ECMO) also plays an important role in the management of
complex patients with acquired and congenital heart disease. We have
successfully utilized ECMO to resuscitate patients following an event
during CC, and transported patients on ECMO from the CICU to the
catheterization Laboratory (CL) for diagnostic and interventional CC.
We report our recent ECMO and CC experience.
Method:
A retrospective analysis of our Children’s Hospital ECMO
database was performed from 2001-2003. Patient demographics,
procedures, complications and outcomes were reviewed.
Results:
A total of 55 ECMO patients, age range 2 days-24 years and weight
range 2.0-90 kg, underwent a total of 59 CC procedures (4 patients
had repeat CC). Patients were either transferred from the CICU to
the CL and supported on ECMO during CC (n= 40, 73%) or were placed on
ECMO electively or emergently in the CL (n=15, 27%). Indications for
CC for ICU patients on ECMO included: 1. Diagnostics (hemodynamic
data or evaluation of a repair) or cardiac biopsy (n=22, 40%) and, 2.
Interventional procedures, including balloon atrial septostomy,
vascular or septal dilation and/or stenting, LA vent placement,
(n=18, 33%). A total of 14 (25%) patients underwent placement of
LA vents, placed in the CL either at the time of cannulation or
during an interventional catheterization. The outcome for the 40
patients transported to the CL on ECMO included: support withdrawn
(n=12, 30%), decannulated / late death (n=7, 17%) and survived to
discharge (n=21, 53%).
ECMO was initiated in the CL on 15 (27%) occasions, 11
(20%) emergently (i.e., pulseless circulation receiving CPR) and 4
(7%) elective. Patients placed electively on ECMO in the CL
included: 1. three patients in a low cardiac output state refractory
to maximal heart failure therapy, 2. one patient transitioned from an
Intra-Aortic Balloon Pump to ECMO for radio-frequency ablation (RFCA)
secondary to arrhythmia. The outcome for the 15 patients placed on
ECMO in the CL included, life support withdrawn (n=1, 6%)
decannulated / late death (n=4, 27%), and survived to discharge
(n=10, 67%). All four patients electively cannulated in the CL
survived to hospital discharge (n=4,100%): One required cardiac
surgery, one RFCA, and two went on to Heart transplantation (OTx);
One of the OTx patients was transitioned to Ventricular Assist Device
pre transplant. Our rapid response ECMO system was deployed on
11occassions for urgent cannulation during CPR secondary to an
unexpected CC complication; 8/11 (73%) survived to discharge. ECMO
related complications occurred in only 2 (4%) patients, both
involving air into venous limb of the circuit. In both cases the air
was evacuated and support was re-established without incident. One
patient received an additional heparin bolus 100u/kg, despite being
already systemically heparinized at the time of CC. Despite this,
there was no bleeding complication. ECMO patients in the CL no
longer receive a heparin bolus, and systemic heparization is
increased to achieve ACT’s of >220 secs.
Conclusion:
Extra-corporeal Life Support can be safely utilized in the
Cardiac Catheterization Laboratory to aid in the diagnosis and
intervention of patients with acquired or congenital heart disease.
The CL is an unfamiliar and crowded environment and the management of
ECMO requires a collaborative effort of well trained personnel.