Venovenous versus venoarterial extracorporeal membrane oxygenation in congenital diaphragmatic hernia

doi:10.1016/S0022-3468(03)00256-2

Journal of Pediatric Surgery

Volume 38, Issue 8, August 2003, Pages 1131-1136

https://doi.org/10.1016/S0022-3468(03)00256-2 Get rights and content

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) has a significant role as a final rescue modality in severe respiratory failure of the newborn with congenital diaphragmatic hernia (CDH). The objective of this study was to compare the efficiency of venovenous (VV) versus venoarterial (VA) ECMO in newborns with CDH.

Methods: A retrospective report of 11 years experience (1990 through 2001) of a single center, comparing VV and VA ECMO is given. VV ECMO was the preferred rescue modality for respiratory failure unresponsive to maximal medical therapy. Only when the placement of a VV ECMO 14F catheter was not possible, VA ECMO was used. Forty-six patients met ECMO criteria; 26 were treated with VV ECMO and 19 with VA ECMO. One patient underwent conversion from VV to VA ECMO.

Results: Before ECMO, there was no difference between VV and VA ECMO patients in mean oxygenation index (83 v 83), mean airway pressure (18.4 v 18.9 cm H₂O), ECMO cannulation age (28 v 20 hours), or in the percentage of patients who needed dopamine and dobutamine (100% v 100%). From November 1994, nitric oxide (NO) was available; before ECMO, 11 of 14 (79%) VV ECMO patients received NO versus 9 of 10 (90%) patients in the VA group. VV ECMO patients were larger (3.34 v 2.77 kg; P < .05) and of advanced gestational age (39.0 v 36.9 wk; P < .05) compared with VA ECMO patients. There was no significant difference between VV and VA ECMO patients in survival rate (18 of 26, 69% v 13 of 19, 68%), ECMO duration (152 v 150 hours), time of extubation (32.0 v 33.5 days), age at discharge (73 v 81 days), or incidence of short-term intracranial complications (3.8% v 10.5%) or myocardial stun (3.8% v 15.8%).

Conclusions: The authors conclude that VV ECMO is as reliable as VA ECMO in newborns with CDH in severe respiratory failure who need ECMO support and who can accommodate the VV double-lumen catheter. Because of its potential advantages, VV ECMO may be the preferred ECMO method in these infants.

Section snippets

Materials and methods

VV ECMO was introduced at Huntington Memorial Hospital (Pasadena, CA) in October 1990. Only infants with intractable respiratory failure unresponsive to maximal medical therapy who met ECMO criteria and whose parents gave informed consent were placed on ECMO. VV ECMO was the preferred mode of ECMO. An attempt was made to place a 14 F double-lumen VV catheter (Kendall Infant ECMO Catheter, catalog No. 5914; Kendall Healthcare Products Co, Mansfield, MA) in all infants who met ECMO criteria. The

Results

There were 99 patients with CDH treated at our institution during the time of the study; 46 (46%) of these infants were treated with ECMO. A total of 27 newborns with CDH received VV ECMO. One of them required conversion to VA ECMO (this infant survived). Nineteen newborns with CDH were treated with VA ECMO (Fig 1).

Patient characteristics are given in Table 1. VV ECMO patients were larger and of advanced gestational age compared with VA ECMO patients. This probably was dictated by the ability

Discussion

Our study found that VV ECMO was as efficient as VA ECMO in supporting newborn infants with CDH with intractable respiratory failure who could accommodate the 14 F VV ECMO double-lumen catheter. Our report is based on a retrospective review of 26 VV ECMO and 19 VA ECMO patients in a single center that had made preference of the VV ECMO with a surgical team experienced in this technique. Patients placed on VV ECMO had a comparable severity of their respiratory as well as of their cardiovascular

Acknowledgements

The authors thank the neonatologists and the staff of the Neonatal ECMO Program at Huntington Memorial Hospital for their contributions and support with the study. Dr. Ernesto Gangitano works for Pediatrix Medical Group Inc.

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Management of the CDH patient on ECLS
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Congenital diaphragmatic hernia (CDH) is the most common indication for respiratory extracorporeal life support (ECLS) in neonates. The survival rate of CDH neonates treated with ECLS is 50%, and this figure has remained relatively stable over the last few decades. This is likely because the current population of CDH neonates who require ECLS have a higher risk profile [1]. The management of neonates with CDH has evolved over time to emphasize postnatal stabilization, gentle ventilation, and multi-modal treatment of pulmonary hypertension. In order to minimize practice variation, many centers have adopted CDH-specific clinical practice guidelines, however care is not standardized between different centers and outcomes vary [3]. The purpose of this review is to summarize our current understanding of issues central to the care of neonates with CDH treated with ECLS and specifically highlight how the use of the Extracorporeal Life Support Organization (ELSO) data have added to our understanding of CDH.
The role of ECMO in the management of congenital diaphragmatic hernia
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Mode of cannulation is most often dictated by institutional preference or the perceived degree of illness of the neonate.32 A number of studies have compared VV versus VA ECMO for CDH and none have reported a difference in mortality.4,36,37 These studies were criticized for not being able to adequately control for disease severity or selection bias.38
Congenital diaphragmatic hernia (CDH) is the most common indication for extra-corporeal membrane oxygenation (ECMO) for neonatal respiratory failure. CDH management is evolving with advanced prenatal diagnostic imaging modalities. The risk profiles of infants receiving ECMO for CDH are shifting towards higher risk. Many clinicians are developing and following clinical practice guidelines to standardize and optimize the care of CDH neonates. Despite these efforts, there are significant differences in the practice patterns among ECMO centers as to how and when they choose to initiate ECMO for CDH, when they believe repair is safe, as well as many other nuances that are based on center experience or style. The purpose of this report is to summarize our current understanding of the new and recent developments regarding management of infants with CDH managed with ECMO.
Venovenous Extracorporeal Membrane Oxygenation for Patients With Return of Spontaneous Circulation After Cardiac Arrest Owing to Acute Respiratory Distress Syndrome
2019, Journal of Cardiothoracic and Vascular Anesthesia
The primary objective of this study was to determine the survival to hospital discharge of patients who were treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO) for respiratory failure after cardiac arrest.
Retrospective chart review.
University-affiliated tertiary care hospitals.
The study comprised 21 patients.
Implementation of VV ECMO in patients with return of spontaneous circulation after cardiac arrest owing to respiratory insufficiency.
The most common etiology of arrest was pneumonia-associated acute respiratory distress syndrome (8/21 [38%]). Overall, 12/21(57%) patients survived to hospital discharge. Two of 12 (17%) patients required hemodialysis upon discharge.
VV ECMO may be an appropriate alternative to venoarterial ECMO in select patients with return of spontaneous circulation after cardiac arrest owing to profound respiratory failure.
Management preferences in ECMO mode for congenital diaphragmatic hernia
2019, Journal of Pediatric Surgery
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This suggests that even though most centers report working as a multidisciplinary team on ECMO infants, each group of physicians is associated with their own biases. This bias against VV-ECMO is despite mounting evidence that it is at least no different in terms of survival [24–26], if not advantageous in some scenarios [27]. The Canadian CDH Collaborative recommends the routine use of prenatal ultrasound measurement of observed-to-expected lung-head ratios (O/ELHR) [19].
The purpose of this study was to identify management preferences that may exist in the care of infants with CDH receiving ECMO with emphasis on VV-ECMO.
A survey was created to measure treatment preferences regarding ECMO use in CDH. The survey was distributed to all APSA and ELSO/Euro-ELSO members via e-mail. Survey results were summarized using descriptive statistics.
The survey had 230 respondents. The survey participants were surgeons (75%), neonatologists/intensivists (23%), and “other” (2%). The mean annual center volume was 11.6(± 9.6) CDH cases, and the average number treated with ECMO was 4.5 (± 6.4) cases/yr. The most agreed upon criteria for ECMO initiation were preductal O₂ saturation < 80% refractory to ventilator manipulation and medical therapy (89%), oxygenation index > 40 (80%), severe air-leak (79%), and mixed acidosis (75%). Over 60% of respondents agreed the VV-ECMO would be optimum for average risk neonates. However, this preference diminished as the pre-ECMO level of cardiac support increased. When asked about why each respondent would choose VA-ECMO over VV-ECMO, the responses varied significantly between surgeons and non-surgeons.
While there seem to be areas of consensus among practitioners, such as criteria for initiation of ECMO, this survey revealed substantial variation in individual practice patterns regarding the use of ECMO for CDH.
Qualitative, Survey.
IV.
Outcomes of infants with congenital diaphragmatic hernia treated with venovenous versus venoarterial extracorporeal membrane oxygenation: A propensity score approach
2018, Journal of Pediatric Surgery
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In the matched groups, the odds of death were not different between VA and VV ECMO. This overall result is in agreement with what was previously reported [4, 6, 15]. If VV ECMO is deemed insufficient to meet the hemodynamic needs of the patient, the only option is conversion to VA ECMO.
Previous studies comparing extracorporeal membrane oxygenation (ECMO) modality for congenital diaphragmatic hernia (CDH) have not accounted for confounding by indication. We therefore hypothesized that using a propensity score (PS) approach to account for selection bias may identify outcome differences based on ECMO modality for infants with CDH.
We utilized ELSO Registry data (2000–2016). Patients with CDH were divided to either venoarterial (VA) or venovenous (VV) ECMO. Patients were matched by PS to control for nonrandom treatment assignment. Subgroup analyses were conducted based on timing of CDH repair relative to ECMO. Primary analysis was the “intent-to-treat” cohort based on the initial ECMO mode. Mortality was the primary outcome, and severe neurologic injury (SNI) was a secondary outcome.
PS matching (3:1) identified 3304 infants (VA = 2470, VV = 834). In the main group, mortality was not different between VA and VV ECMO (OR = 1.01, 95% CI: 0.86–1.18) and there was no difference in SNI between VA and VV (OR = 0.80; 95% CI: 0.63–1.01). For the pre-ECMO CDH repair subgroup, 175 VA cases were matched to 70 VV. In these neonates, mortality was higher for VV compared to VA (OR = 2.10, 95% CI: 1.19–3.69), without any difference in SNI (OR = 1.48; 95% CI: 0.59–3.71). For the subgroup that did not have pre-ECMO CDH repair, 2030 VA cases were matched to 683 VV cases. In this subgroup, VV was associated with 27% lower risk of SNI relative to VA (OR = 0.73, 95% CI: 0.56–0.95) without any difference in mortality (OR = 0.94, 95% CI: 0.79–1.11).
This study revalidates that ECMO mode does not significantly affect mortality or SNI in infants with CDH. In the subset of infants who require pre-ECMO CDH repair, VA favors survival, whereas, in the subgroup of infants that did not have pre-ECMO CDH repair, VV favors lower rates of SNI. We conclude that neither mode appears consistently superior across all situations, and clinical judgment should remain a multifactorial decision.
Level III.
Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia
2018, Seminars in Perinatology
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Over the past 2 decades, several studies have shown equivalent outcomes for infants treated with VA versus VV ECMO. Single center studies demonstrated no difference in ECMO duration, hospital length of stay, and neurologic or catheter complications when comparing VV to VA ECMO.41–44 One center reported increased mortality and another reported increased ventilator days in the VA ECMO group, and all other reported outcomes were similar.41,42
Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly which impairs normal pulmonary development leading to acute and chronic respiratory failure, pulmonary hypoplasia, pulmonary hypertension, and mortality. CDH is the most common non-cardiac indication for neonatal ECMO. Prenatal and postnatal predictors of CDH severity aid in patient selection. Centers vary in preferred mode of ECMO and timing of CDH repair. Survivors of severe CDH with ECMO are at risk for long-term sequelae including neurodevelopmental delays.

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