Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass.
Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Biostatistics, Harvard Medical School, Boston, Mass.
J Thorac Cardiovasc Surg. 2023 Jun;165(6):2181-2192.e2. doi: 10.1016/j.jtcvs.2022.06.028. Epub 2022 Aug 6.
Data regarding the influence of intraoperative residual lesions on extracorporeal membrane oxygenation (ECMO) following the Norwood procedure are limited. Moreover, the significance of postoperative ECMO timing on in-hospital outcomes remains incompletely characterized.
This was a single-center, retrospective review of consecutive patients who underwent the Norwood operation from January 1997 to November 2017. Patients with at least minor residual lesions based on the intraoperative postcardiopulmonary bypass echocardiogram were identified. The association between residual lesions and postoperative ECMO was assessed with logistic regression, adjusting for age, weight, prematurity, various preoperative system-specific and procedural risk factors, shunt type, and era. Among patients receiving ECMO, associations between late ECMO (≥3 days post-Norwood) and in-hospital mortality or transplant, postoperative hospital length-of-stay, and cost of hospitalization were evaluated using logistic regression or generalized linear models with a gamma distribution and logarithmic link.
Among 500 patients, 78 (15.6%) received ECMO postoperatively. On multivariable analysis, the presence of at least minor residual lesions (odds ratio, 4.4; 95% CI, 2.1-9.3; P < .001) was associated with postoperative ECMO. In the ECMO subpopulation, there were 44 (56.4%) deaths or transplants. Late ECMO was associated with increased risk of in-hospital mortality or transplant (adjusted odds ratio, 6.2; 95% CI, 1.5-26.0), longer postoperative hospital length of stay (regression coefficient, 0.7; 95% CI, 0.3-1.1), and greater cost (regression coefficient, 0.6; 95%, CI 0.4-0.7), versus early ECMO (all P values < .05).
The presence of even minor intraoperative residua significantly increases the risk of ECMO following the Norwood operation. Among patients receiving ECMO postoperatively, early institution of ECMO is associated with lower mortality and resource utilization.
关于体外膜肺氧合（ECMO）在体外循环后对 Norwood 手术后的影响的数据是有限的。此外，术后 ECMO 时机对住院结果的意义仍不完全明确。
这是一项单中心回顾性研究，纳入了 1997 年 1 月至 2017 年 11 月期间接受 Norwood 手术的连续患者。根据体外循环后超声心动图，确定至少存在轻微残余病变的患者。使用逻辑回归评估残余病变与术后 ECMO 的关系，并根据年龄、体重、早产、各种术前系统特异性和手术风险因素、分流类型和时代进行调整。在接受 ECMO 的患者中，使用逻辑回归或具有伽马分布和对数链接的广义线性模型评估晚期 ECMO（Norwood 手术后≥3 天）与住院期间死亡率或移植、术后住院时间和住院费用之间的关系。
在 500 名患者中，78 名（15.6%）术后接受 ECMO。多变量分析显示，至少存在轻微残余病变（比值比，4.4；95%置信区间，2.1-9.3；P<.001）与术后 ECMO 相关。在 ECMO 亚组中，有 44 名（56.4%）死亡或移植。晚期 ECMO 与住院期间死亡率或移植的风险增加相关（调整比值比，6.2；95%置信区间，1.5-26.0），术后住院时间延长（回归系数，0.7；95%置信区间，0.3-1.1）和更高的成本（回归系数，0.6；95%置信区间，0.4-0.7），与早期 ECMO 相比（所有 P 值<.05）。
即使存在轻微的术中残余病变，也会显著增加 Norwood 手术后 ECMO 的风险。在接受术后 ECMO 的患者中，早期建立 ECMO 与较低的死亡率和资源利用率相关。
