ECMO in Neonates: A Brief Review

The history of extracorporeal membrane oxygenation (ECMO) in neonates began in 1975 when Dr. Bartlett and colleagues at the University of Irvine, CA successfully treated a 1-day-old newborn with severe persistent pulmonary hypertension of the newborn (PPHN) utilizing ECMO after conventional therapies had failed [1].

Since then, the use of ECMO in neonates has evolved significantly due to improved understanding of neonatal cardiopulmonary pathophysiology and advanced ECMO technology. As documented by the Extracorporeal Life Support Organization (ELSO), from 1989 to 2020, the registry reported that 43,707 neonates had been supported with ECMO worldwide [2].

Indications for ECMO in Neonates

Respiratory Indications

Historically, meconium aspiration syndrome, PPHN, and neonatal respiratory distress syndrome were the most common ECMO indications in neonates. Over time, the incidence of these indications has declined due to improved perinatal care. Currently, about one-third of ECMO neonatal diagnosis is represented by congenital diaphragmatic hernia (CDH) [3].

Congenital Heart Disease

In neonates with congenital heart disease (e.g., transposition of the great arteries with pulmonary hypertension), ECMO has been used for pre-operative stabilization, failure to wean from cardiopulmonary bypass, and low cardiac output syndrome post-operatively. Following congenital heart surgery, ECMO has been utilized in 1.4–5% of operations [4-6].

Myocarditis / Cardiomyopathy

Although rare, neonatal myocarditis/cardiomyopathy may require ECMO to maintain end-organ perfusion. In these cases, ECMO may be used as a bridge to recovery, to heart transplantation or ventricular assist device, or to decision-making. 

Cardiac Failure / Arrhythmias

ECMO may be indicated in neonates with cardiac failure associated with septic shock or cardiac arrest and severe arrhythmias. Arrhythmias may occur in the perinatal period, postoperatively, or in myocarditis/cardiomyopathy. In these cases, ECMO support is generally used to maintain end-organ perfusion while optimizing pharmacological and/or surgical treatment.

Timing and Duration of ECMO in Neonates

Significant debate surrounds the timing for ECMO deployment in neonatal cardiac failure. Some studies show early initiation may reduce hypoxia of the myocardium and/or peripheral organs [8]. However, prolonged ECMO in neonates with cardiac disease carries a high mortality and reduces the chances of a successful heart transplant [9]. 

Survival drops from 45 % (overall survival of children with cardiac disease) to:

• 23–25 % when ECMO duration is between 14 and 28 days 
• 13% when ECMO is used more than 28 days [10]

Meanwhile, prolonged respiratory ECMO > 21 days has a reported survival rate of 23.5% [11].

Based on multiple considerations, when evaluating ECMO as a bridge to a ventricular assist device, its duration should not be longer than 5–7 days [12].

Overall Survival Rates for ECMO in Neonates

Hospital survival when using ECMO in neonates is around 40%. This figure has remained relatively constant despite cumulative ECMO clinical experience, improved equipment, and advanced understanding of neonatal cardiopulmonary pathophysiology. 

Rather than being a failure to improve, the unchanged survival rate may be due to a constant widening of indications and increasingly complex patient risk profiles [13]. 

Conclusion

ECMO has been utilized in the treatment of neonates with severe cardiopulmonary disease for nearly five decades. ECMO is now an essential care option for newborns with severe heart failure as a bridge to recovery, long term mechanical support, or transplantation.

Click here to learn more about ECMO treatment for acute respiratory failure or acute cardiopulmonary failure. 

References:

1. Bartlett RH (2017) Esperanza: the first neonatal ECMO patient. ASAIO J 63(6):832–843
2. Extracorporeal Life Support Organization (2020) ECLS Registry Report. International summary – July 2020. Available on January 8, 2021; from https://www.elso.org
3. Extracorporeal Life Support Organization (2020) ECLS Registry Report. International summary – July 2020. Available on January 8, 2021; from https://www.elso.org
4. Mascio CE, Austin EH, Jacobs JP, Jacobs ML, Wallace AS, He X, et al. Perioperative mechanical circulatory support in children: an analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. J Thorac Cardiovasc Surg. (2014) 147:658–64. doi: 10.1016/j.jtcvs.2013.09.075
5. Salvin JW, Laussen PC, Thiagarajan RR. Extracorporeal membrane oxygenation for postcardiotomy mechanical cardiovascular support in children with congenital heart disease. Paediatr Anaesth. (2008) 18:1157–62. doi: 10.1111/j.1460-9592.2008.02795.x
6. Sasaki T, Asou T, Takeda Y, Onakatomi Y, Tominaga T, Yamamoto Y. Extracorporeal life support after cardiac surgery in children: outcomes from a single institution. Artif Organs. (2014) 38:34–40. doi: 10.1111/aor.12191
7. Amodeo, I., Di Nardo, M., Raffaeli, G. et al. Neonatal respiratory and cardiac ECMO in Europe. Eur J Pediatr 180, 1675–1692 (2021). https://doi.org/10.1007/s00431-020-03898-9 
8. Ford MA, Gauvreau K, McMullan DM, Almodovar MC, Cooper DS, Rycus PT et al (2016) Factors associated with mortality in neonates requiring extracorporeal membrane oxygenation for cardiac indications. Pediatr Crit Care Med 17(9):860–870
9. Merrill ED, Schoeneberg L, Sandesara P, Molitor-Kirsch E, O’Brien J, Dai H et al (2014) Outcomes after prolonged extracorporeal membrane oxygenation support in children with cardiac disease—Extracorporeal Life Support Organization registry study. J Thorac Cardiovasc Surg 148(2):582–588
10. Roeleveld PP, Mendonca M (2019) Neonatal cardiac ECMO in 2019 and beyond. Front Pediatr 7(August):1–13
11. Sharma J, Sherman A, Rimal A, Haney B, Weiner J, Pallotto E (2020) Neonatal respiratory extracorporeal membrane oxygenation and primary diagnosis: trends between two decades. J Perinatol 40(2):269–274
12. Roeleveld PP, Mendonca M (2019) Neonatal cardiac ECMO in 2019 and beyond. Front Pediatr 7(August):1–13
13. Barbaro RP, Paden ML, Guner YS, Raman L, Ryerson LM, Alexander P, et al., Pediatric extracorporeal life support organization registry international report 2016. ASAIO J. (2017) 63:456–63. doi: 10.1097/MAT.0000000000000603