Peer Syed M, Costello John P, Klein Joshua C, Engle Alyson M, Zurakowski David, Berger John T, Jonas Richard A, Nath Dilip S
Division of Cardiovascular Surgery, Children's National Health System, Washington, DC.
Division of Cardiovascular Surgery, Children's National Health System, Washington, DC; The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC.
Ann Thorac Surg. 2014 Dec;98(6):2152-7; discussion 2157-8. doi: 10.1016/j.athoracsur.2014.07.042. Epub 2014 Oct 29.
Extracorporeal membrane oxygenation (ECMO) support is often required in the management of perioperative congenital heart surgery (CHS) patients. However, 24-hour in-hospital congenital cardiac surgical coverage (24-CCSC) is not available at all institutions. The purpose of this study is to evaluate the effect of 24-CCSC on perioperative ECMO outcomes in CHS patients.
An institutional review board approved, retrospective review of 128 perioperative CHS ECMO patients at a single, quaternary care children's hospital between January 2003 and December 2012 was performed. Primary endpoints evaluated were mortality in children supported with ECMO after undergoing cardiac surgery and ECMO-related morbidity after initiation of 24-CCSC with advanced congenital cardiac surgical fellows. Patients were divided into 2 groups based on whether 24-CCSC was absent (cohort 1: January 2003 to July 2007) or present (cohort 2: August 2007 to December 2012) at the time of ECMO management.
The surgical procedures performed were similar in both cohorts based on STAT Mortality Categories (5 Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories). The overall mortality rate in children supported with ECMO after undergoing cardiac surgery was 53%. This mortality was significantly reduced from 68% to 43% (p = 0.007) with 24-CCSC. Multivariate logistic regression analysis revealed that 24-CCSC (p = 0.009) and lower STAT Mortality Category (p = 0.042) were independent predictors of operative survival. Cardiac arrhythmias (36% to 16%; p = 0.012) and pulmonary complications (32% to 8%; p < 0.001) were significantly reduced with 24-CCSC.
The presence of 24-CCSC significantly decreased the rate of mortality in children supported with ECMO after undergoing cardiac surgery, as well as cardiac arrhythmias and pulmonary complications for perioperative CHS patients receiving ECMO support. This study demonstrates that CHS programs would benefit from 24-CCSC in the care of this critically ill patient population.
围手术期先天性心脏病手术（CHS）患者的管理通常需要体外膜肺氧合（ECMO）支持。然而，并非所有机构都能提供24小时院内先天性心脏手术覆盖（24-CCSC）。本研究的目的是评估24-CCSC对CHS患者围手术期ECMO结局的影响。
对一家四级护理儿童医院在2003年1月至2012年12月期间的128例围手术期CHS ECMO患者进行了机构审查委员会批准的回顾性研究。评估的主要终点是心脏手术后接受ECMO支持的儿童的死亡率以及由高级先天性心脏外科住院医师启动24-CCSC后的ECMO相关发病率。根据在ECMO管理时是否存在24-CCSC，将患者分为两组（队列1：2003年1月至2007年7月；队列2：2007年8月至2012年12月）。
根据STAT死亡率类别（5种胸外科医师协会-欧洲心胸外科协会先天性心脏病手术死亡率类别），两个队列中进行的外科手术相似。心脏手术后接受ECMO支持的儿童的总体死亡率为53%。有了24-CCSC后，这一死亡率从68%显著降低至43%（p = 0.007）。多因素逻辑回归分析显示，24-CCSC（p = 0.009）和较低的STAT死亡率类别（p = 0.042）是手术生存的独立预测因素。有了24-CCSC后，心律失常（从36%降至16%；p = 0.012）和肺部并发症（从32%降至8%；p < 0.001）显著减少。
24-CCSC的存在显著降低了心脏手术后接受ECMO支持的儿童的死亡率以及接受ECMO支持的围手术期CHS患者的心律失常和肺部并发症发生率。本研究表明，CHS项目在护理这一危重症患者群体时将从24-CCSC中受益。
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