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Articles by Children’s Heart Center Physicians
Airborne Transfer Of Patients On Excorporeal Membrane Oxygenator (ECMO) Support
William P. Fiser, Sana Ullah, LL Baker, CW Chipman, BJ Taylor, Anji Yetman, Michael Schmitz, Stephen Van Devanter, JJ Drummond-Webb Arkansas Children’s Hospita University of Arkansas for Medical Science Divisions of Pediatric Cardiac Surgery, Pediatric Cardiac Anesthesiology and Cardiology Introduction: Airborne circulatory support during the transport of critically ill patients imposes significant logistic, mechanical, and physiological problems. Requirements for airborne ECMO transportation have required circuit changes specific to a roller-pump system with a computer aided perfusion system, custom built frames for helicopter and fixed wing use, and the ability to function independently of the ECMO/intensive care unit for a prolonged period of time. Methods: An IRB-approved database for ECMO patients was custom-designed and maintained. This database was examined to assess the patient outcomes. Results between 1990 and 2002: 53 patients have been transported on ECMO by air. Of these, 95% were placed on ECMO by our team at the referral site. Three transports occurred from the referral site to another institution. Transport was by helicopter in 48 patients, fixed–wing aircraft in five. Ages range from one day of life to 68 years of age. Only eight patients were adults. The median transport distance was 150 miles (range 5-995 miles). Overall, 50% of transported patients were long-term survivors. There was no mortality incurred during transport. Long-term survival was only 13% in adult patients (of which one received a cardiac transplant) and 27% amongst pediatric patients with cardiac diagnoses. Of the pediatric cardiac transports, 27% were attempted salvages of failed cardiovascular surgical procedures at other institutions. There was only one survivor in this group. Significantly increased long-term survival (73%, p<.01) was noted amongst neonates and pediatric patients with medical diagnoses. Step-wise logistic regression failed to document age to be statistically significant, and medical diagnosis vs cardiac diagnosis was highly significant (p<.01). Conclusion: Transplantation after ECMO placement can be safely achieved, provided appropriate air, medical, and physiologic considerations are taken into account. Long-term survival was affected by the preintervention diagnosis. Children with a noncardiac illness requiring ECMO airborne transport have a much better chance of survival vs children with a cardiac diagnosis. Adults and patients who have failed cardiac surgery have a very poor prognosis. THE EXTRA CARDIAC FONTAN PROCEDURE WITHOUT CARDIOPULMONARY BYPASS – TECHNIQUE AND INTERMEDIATE TERM RESULTS Anji T. Yetman, M.D., Jonathan Drummond-Webb, M.D., William
P. Fiser, M.D., Michael L. Schmitz, M.D. , Michiaki Imamura,
M.D.,PhD, Sana Ullah, M.D.,
Ryan J. Gunselman, BSPS, Carl W Chipman, RN, CCP, Charles E. Johnson RN, CCP
, Stephen H. Van Devanter, M.D. Extracardiac Fontan Without Bypass MEETING PRESENTATION: Current Trends in Thoracic Surgery VIII. Best Five Original Presentations. January 23 - 26, 2002. Miami, Florida. Jonathan Drummond-Webb, M.D. ABSTRACT Background: The extracardiac Fontan usually requires the use of cardiopulmonary bypass. Results and techniques of this procedure without cardiopulmonary bypass at a single institution are presented. Methods: Between August 1992 and December 2001, the extracardiac Fontan procedure without cardiopulmonary bypass was achieved in 24 out of 44 patients undergoing extracardiac Fontan. Mean age at surgery was 5.9 ± 2.9 years and mean weight 20.7 ± 12.6 kg. Diagnoses were tricuspid atresia in 9 patients, single ventricle with pulmonary outflow tract obstruction in 7, pulmonary atresia /intact septum in 5, and other complex single ventricle physiology in 3. Initial palliation was by arterial to pulmonary artery shunt in 21 and pulmonary artery banding in 1. A bi-directional cavopulmonary connection was created in 23 patients. A temporary inferior vena caval to atrial shunt was used to complete the procedure without cardiopulmonary bypass. Median graft size was 16mm (range 14-20 mm). Results: There was no early mortality, and 68% were discharged
without complications. Complications included persistent cyanosis in 4, persistent
pleural effusions, in 2 (1 chylous), and one phrenic nerve injury. Median postoperative
hospital stay was 16 (10-50) days. At a mean follow-up of 44 ± 28 months,
there was no conduit obstruction. One patient died 11 months post operatively,
and one patient received a heart transplant 26 months post ECF. PEDIATRIC ARTERIO-VENOUS EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) AS A BRIDGE TO CARDIAC TRANSPLANTATION *William P. Fiser, M.D., #Anji T. Yetman, M.D., *Ryan J. Gunselman, #James W Fasules, M.D., *Lorrie L. Baker, R.N., *Carl W. Chipman, R.N., C.C.P., # William R Morrow M.D., #Elizabeth A. Frazier, M.D., *Jonathan J. Drummond-Webb, M.D.; *Pediatric and Congenital Cardiac Surgery, Arkansas Children's Hospital, Little Rock, AR, United States; Surgery and Division of Cardiothoracic Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, United States; #Pediatric Cardiology, Arkansas Children's Hospital, Little Rock, AR, United States. Corresponding Author: ABSTRACT Background: Since 1990, ECMO has been used as a bridge to cardiac transplantation in 47 patients. Methods: A review of the ACH, IRB approved, ECMO database forms the basis of this report. Statistical comparison used Fisher exact probability testing. ECMO circuitry was a roller occlusion pump with computerized assisted perfusion system technology. Results: Trans-catheter septostomy was used for cardiac decompression in 32 (68%) patients. Diagnosis at presentation was either congenital heart disease (CHD) N=15 or cardiomyopathy (CM) N=32. Ages ranged from 1 day to 22 years (median 18 months) and weight ranged from 2.9 to 100 kg (median 10 kg). The average duration of support was 242 hours (range 22-1078 hours). Overall long-term survival was 47% with 16 (34%) patients successfully bridged to cardiac transplant (of which 9 [56%] survived) and 13 (28%) successfully weaned from ECMO. Patients placed on ECMO post-cardiotomy had a 31% survival. Survival was significantly improved (p< .02) in patients with a diagnosis of CM (59%) versus those with CHD (20%). Patients with CM underwent 8 transplants with 7 survivors (88%), while in the CHD group, there were 8 transplants with only 2 survivors (25%), (p< .05). Sub analysis of the CM group revealed that patients with acute cardiomyopathy in association with a documented viral illness had a 75% chance of being weaned off ECMO without transplant. Complications on ECMO occurred in 45% of survivors and were more frequent in non-survivors. Infectious complications were most frequent, followed by neurological, technical ECMO problems and renal insufficiency. Conclusions: In conclusion, CM has a better prognosis than CHD when using ECMO as a bridge to transplant or survival. Complications are not insignificant and increase with the duration of support. ECMO for salvage and subsequent transplant in this high-risk group of patients needs critical review. Alternative support options need to be developed in the pediatric population that will allow improved outcomes comparable to those achieved by our adult support colleagues. A Heart Hospital In A Hospital | Heart Conditions, Diagnosis and Treatment | Patient Stories & Videos The Heart Team | Outpatient Services | Going to the Heart Center | Further Reading & Resources Heart to Heart Newsletter | Contact Information | Heart Home
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