2004 OPEN FORUM Abstracts
Safe Utilization of Extra-Corporeal Membrane Oxygenation during Cardiac Catheterization in Patients with Heart Disease
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 The outcome for the 40 patients transported to the CL on ECMO included: support withdrawn (n=12, 30%), decannulated / late death (n=7, 17%) and survived to discharge (n=21, 53%).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 The outcome for the 15 patients placed on ECMO in the CL included, life support withdrawn (n=1, 6%) decannulated / late death (n=4, 27%), and survived to discharge (n=10, 67%).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.