Original article
Congenital heart surgery
Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation

https://doi.org/10.1016/j.athoracsur.2015.06.020Get rights and content

Background

Stroke is a common complication of extracorporeal membrane oxygenation (ECMO), and pediatric cardiac surgical patients may be at higher risk. Epidemiology and risk factors for stroke in these patients are not well characterized.

Methods

We analyzed pediatric (<18 years) cardiac ECMO cases in the Extracorporeal Life Support Organization Registry from 2002 to 2013. Cardiac surgical patients were identified, and procedures were stratified according to The Society of Thoracic Surgeons morbidity categories. The primary outcome was any stroke (hemorrhagic or infarction) identified by neuroimaging. Risk factors were identified through multivariable logistic regression.

Results

We analyzed 3,517 cardiac surgical patients; 81% with cyanotic disease, and 57% in high-risk categories from The Society of Thoracic Surgeons (categories 4 and 5). Overall, 12% experienced stroke while receiving ECMO, and those with stroke had greater in-hospital mortality (72% versus 51%; p < 0.0001). In multivariable analysis, neonatal status (adjusted odds ratio, 1.8; 95% confidence interval, 1.3 to 2.4), lower weight-for-age z score (adjusted odds ratio, 1.1 for each 1-point decrease; 95% confidence interval, 1.04 to 1.25), and longer ECMO duration (upper quartile [≥167 hours] adjusted odds ratio, 1.4; 95% confidence interval, 1.1 to 1.8) were independently associated with increased stroke risk, whereas cyanotic disease, The Society of Thoracic Surgeons category, and bypass time were not.

Conclusions

This multicenter analysis demonstrates that pediatric cardiac surgical patients on ECMO are at high risk of stroke; younger or underweight patients and those with longer ECMO duration are at greatest risk, independent of procedural complexity. Future study is necessary to determine how anticoagulation or other clinical practices can be modified to reduce stroke incidence.

Section snippets

Data Source

The Extracorporeal Life Support Organization (ELSO) maintains a registry of ECMO data from more than 350 international ECMO centers and currently houses information from greater than 58,000 ECMO runs since 1990. Each participating ECMO center collects and voluntarily reports standardized data on all patients undergoing ECMO including patient characteristics, details of the ECMO run, complications, and outcomes. Centers submit a cardiac addendum for patients who required ECMO for cardiac support

Demographics

Our inclusion criteria identified 3,517 cardiac surgical patients requiring ECMO postoperatively. Characteristics of the cohort are presented in Table 1; 54% were neonates (age <30 days), 96% had structural heart disease (81% cyanotic), and 57% were in STS categories 4 or 5. Extracorporeal membrane oxygenation duration varied considerably (median, 104 hours; interquartile range, 64 to 167).

Stroke and Outcomes

Surgical patients had a 12.3% incidence of stroke with high rates of hemorrhagic stroke (10%), and low

Comment

This is the first multicenter analysis of stroke epidemiology in pediatric cardiac surgical patients on ECMO. We showed the incidence of hemorrhagic stroke is higher and the incidence of ischemic stroke is lower in cardiac surgical patients compared with previously published rates in mixed cohorts of children on ECMO [4], and that the risk of death is greatly increased in patients with stroke. Neonatal age, lower weight-for-age z score, and longer ECMO duration were independently associated

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