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Intro: The presence of right ventricular (RV) dysfunction is common among pediatric and adult patients with acute respiratory distress syndrome (ARDS) and is associated with increased mortality. Typically, RV dysfunction that is secondary to ARDS improves with cannulation to venovenous (VV) extracorporeal membrane oxygenation (ECMO). However, some adult patients develop new RV dysfunction on ECMO that is associated with worse outcomes. No published studies have evaluated the incidence and outcomes of RV dysfunction among pediatric patients on VV ECMO for ARDS.
Methods: A single center retrospective case series was conducted from January 2010 to September 2022. 25 neonatal and pediatric patients cannulated on VV ECMO for ARDS with an echocardiogram performed during their ECMO run were included. Single ventricle patients were excluded. Echocardiogram reports were reviewed for evidence of qualitative systolic dysfunction.
Results: The majority (23/25, 92%) of patients were cannulated using a dual lumen cannula. Overall, 20/25 (80%) survived to decannulation and 19/25 (76%) survived to ICU discharge. About half (12/25, 48%) had echo evidence of new RV dysfunction during their ECMO run. Of the patients without RV dysfunction, 11/13 (85%) survived to decannulation and 10/13 (77%) survived to ICU discharge. Survival to decannulation and ICU discharge was slightly lower among those with RV dysfunction (9/12, 75%). Despite the high incidence of RV dysfunction, only 3 patients required conversion from VV to VA - 2 due to pulmonary hypertensive crisis with associated RV dysfunction and 1 due to cannula thrombus.
Patients with RV dysfunction had a trend towards longer ECMO run, duration of mechanical ventilation, ICU length of stay and hospital length of stay. RV dysfunction was more common in patients with ECMO runs greater than 21 days (6/10, 60%) compared to those with shorter runs (6/15, 40%). The majority of survivors with RV dysfunction continued to have abnormal echos following decannulation and time to resolution on echo varied from 1 to 181 days after decannulation. Of note, autopsy results, cardiac cath findings and post-ICU deaths in several patients demonstrated failure to diagnose clinically relevant RV injury by echo alone.
Conclusion: New RV dysfunction is common among pediatric patients on VV ECMO for ARDS and is associated with worse outcomes. As VV ECMO becomes increasingly more common it is prudent for providers to evaluate for RV dysfunction as a potential complication and early prognostic imaging marker, especially among patients on ECMO for extended periods of time.
Holton, Cara; Shah, Sanket; and Miller, Jenna, "Right ventricular dysfunction is common among pediatric patients with acute respiratory distress syndrome on venovenous ecmo" (2023). Research at Children's Mercy Month 2023. 3.