Influence of left ventricular unloading on pediatric post-cardiotomy veno-arterial extracorporeal life support outcomes

Meani P, Lorusso R, Kowalewski M, Isgrò G, Cazzaniga A, Satriano A, Ascari A, Bernardinetti M, Cotza M, Marchese G, Ciotti E, Kandil H, Di Dedda U, Aloisio T, Varrica A, Giamberti A, Ranucci M. Influence of left ventricular unloading on pediatric post-cardiotomy veno-arterial extracorporeal life support outcomes. Front Cardiovasc Med. 2022 Aug 10;9:970334. doi: 10.3389/fcvm.2022.970334. PMID: 36035925; PMCID: PMC9399613. Abstract <strong>Background: </strong>The effectiveness of veno-arterial extracorporeal life support (V-A ECLS) in treating neonatal and pediatric patients with complex congenital heart disease (CHD) and requiring cardio-circulatory assistance is well-known. Nevertheless, the influence of left ventricle (LV) distension and its countermeasure, namely LV unloading, on survival and clinical outcomes in neonates and children treated with V-A ECLS needs still to be addressed. Therefore, the aim of this study was to determine the effects of LV unloading on in-hospital survival and complications in neonates and children treated with V-A ECLS. <strong>Methods: </strong>The clinical outcomes of 90 pediatric patients with CHD under 16 years of age supported with V-A ECLS for post-cardiotomy cardiogenic shock (CS) were retrospectively reviewed in relationship with the presence or absence of an active LV unloading strategy. <strong>Results: </strong>The patient cohort included 90 patients (age 19.6 ± 31.54 months, 64.4% males), 42 of whom were vented with different techniques (38 with atrial septostomy (AS) or left atria cannula, two with cannula from LV apex, 1 with intra-aortic balloon pump (IABP), and one with pigtail across the aortic valve). The LV unloading strategy significantly increased the in-hospital survival (odds ratio [OR] = 2.74, 95% CI 1.06-7.08; <em>p</em> = 0.037). On the contrary, extracorporeal cardiopulmonary resuscitation decreased the related survival (OR = 0.32, 95% CI 1.09-0.96; <em>p</em> = 0.041). The most common complications were infections (28.8%), neurological injury (26%), and bleeding (25.6%). However, these did not differently occur in venting and no-venting groups. <strong>Conclusion: </strong>In pediatric patients with CHD supported with V-A ECLS for post-cardiotomy CS, the LV unloading strategy was associated with increased survival.Meani P、Lorusso R、Kowalewski M、Isgrò G、Cazzaniga A、Satriano A、Ascari A、Bernardinetti M、Cotza M、Marchese G、Ciotti E、Kandil H、Di Dedda U、Aloisio T、Varrica A、Giamberti A、Ranucci M. 左心室卸载对儿童体外循环术后静脉-动脉体外生命支持（veno-arterial extracorporeal life support, V-A ECLS）结局的影响. 《Front Cardiovasc Med》. 2022年8月10日;9:970334. DOI: 10.3389/fcvm.2022.970334；PMID: 36035925；PMCID: PMC9399613. 摘要 <strong>背景：</strong>静脉-动脉体外生命支持（V-A ECLS）用于治疗合并复杂先天性心脏病（congenital heart disease, CHD）且需心肺循环支持的新生儿与儿童患者的有效性已得到广泛认可。然而，接受V-A ECLS治疗的新生儿及儿童群体中，左心室（left ventricle, LV）扩张及其应对措施——即左心室卸载——对生存率与临床结局的影响仍有待阐明。本研究旨在探讨左心室卸载对接受V-A ECLS治疗的新生儿与儿童的住院生存率及并发症的影响。 <strong>方法：</strong>本研究回顾性分析了90例因体外循环术后心源性休克（cardiogenic shock, CS）接受V-A ECLS支持的16岁以下先天性心脏病患儿的临床结局，并与是否实施主动左心室卸载策略进行关联分析。 <strong>结果：</strong>本研究纳入的90例患儿年龄为19.6±31.54个月，其中男性占比64.4%；42例患儿采用了不同的左心室卸载技术，包括38例行房间隔造口术（atrial septostomy, AS）或左心房插管、2例行左心室心尖部插管、1例行主动脉内球囊反搏（intra-aortic balloon pump, IABP）、1例行经主动脉瓣猪尾导管置入。左心室卸载策略可显著提高住院生存率（比值比[OR]=2.74，95%置信区间[CI]1.06~7.08；<em>P</em>=0.037）。相反，体外心肺复苏会降低相关生存率（OR=0.32，95%CI 1.09~0.96；<em>P</em>=0.041）。最常见的并发症为感染（28.8%）、神经系统损伤（26%）及出血（25.6%），但上述并发症在卸载组与非卸载组间发生率无显著差异。 <strong>结论：</strong>对于因体外循环术后心源性休克接受V-A ECLS支持的先天性心脏病儿童患者，左心室卸载策略与生存率提升相关。