The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
J Heart Lung Transplant. 2017 Nov;36(11):1209-1216. doi: 10.1016/j.healun.2017.02.003. Epub 2017 Feb 8.
Management of mechanical circulatory support in children with congenital heart disease (CHD) is challenging due to physiologic variations and anatomic limitations to device placement. In this study we examine the use of Berlin Heart EXCOR in CHD patients.
CHD patients were identified from the EXCOR Pediatric Study data set (2007 to 2010). Mortality and serious adverse events were compared between CHD and non-CHD cohorts, and predictors of poor outcomes in the CHD cohort were identified.
CHD was present in 29% (n = 59, 18 with 1-ventricle physiology) of all EXCOR patients (N = 204). Successful bridge (transplant or wean) was less likely in CHD patients compared with non-CHD patients (48% vs 80%; p < 0.01). Among CHD patients, no neonates, 25% of infants (30 days to 1 year) and 65% of children (>1 year) were successfully bridged. Pre-implant congenital heart surgery (CHS) and extracorporeal membrane oxygenation (ECMO) on the same admission occurred in 60% of children ≤1 year of age (83% of neonates, 50% of infants), with 8% survival. Regardless of age, patients who did not have CHS and ECMO had 61% survival. Smaller pump, pre-implant bilirubin >1.2 mg/dl and renal dysfunction were independently associated with mortality.
End-organ function at implant reliably predicts adverse outcomes and should be considered when making implant decisions. EXCOR use in neonates and infants with CHD should be approached cautiously. If patients have undergone pre-implant CHS and ECMO, EXCOR support may not provide any survival benefit. EXCOR support in non-infants with CHD is challenging but can be consistently successful with appropriate patient selection.
由于生理变化和设备放置的解剖限制，儿童先天性心脏病（CHD）患者的机械循环支持管理具有挑战性。在这项研究中，我们研究了柏林心脏 EXCOR 在 CHD 患者中的应用。
从 EXCOR 儿科研究数据集（2007 年至 2010 年）中确定 CHD 患者。比较 CHD 和非 CHD 队列的死亡率和严重不良事件，并确定 CHD 队列中不良预后的预测因素。
所有 EXCOR 患者（N = 204）中 CHD 占 29%（n = 59，18 例 1 心室生理）。与非 CHD 患者相比，CHD 患者成功桥接（移植或脱机）的可能性较低（48%比 80%；p < 0.01）。在 CHD 患者中，没有新生儿，25%的婴儿（30 天至 1 岁）和 65%的儿童（>1 岁）成功桥接。在≤1 岁的儿童中，60%（新生儿 83%，婴儿 50%）同时进行了植入前先天性心脏手术（CHS）和体外膜氧合（ECMO），存活率为 8%。无论年龄大小，未进行 CHS 和 ECMO 的患者存活率为 61%。较小的泵、植入前胆红素>1.2mg/dl 和肾功能障碍与死亡率独立相关。
植入时的终末器官功能可靠地预测不良结局，在做出植入决策时应予以考虑。应谨慎对待 EXCOR 在 CHD 新生儿和婴儿中的应用。如果患者已经接受了植入前的 CHS 和 ECMO，EXCOR 支持可能不会带来任何生存获益。在有 CHD 的非婴儿中，EXCOR 支持具有挑战性，但通过适当的患者选择可以持续成功。
