Is there a role for extracorporeal life support after stage I Norwood?

OBJECTIVES: Controversy still surrounds the use of extracorporeal life support (ECLS) in patients with single ventricle physiology. An analysis of the experience with a group of neonates who underwent stage I Norwood palliation and received ECLS is reported.

METHODS: A retrospective review of hospital records, operative notes and perfusion data was performed in a group of 12 consecutive patients undergoing ECLS in the perioperative period after stage I. An analysis to identify risk factors for poor outcome was performed.

RESULTS: The mean age and weight were 3.9 days (1-14) and 2.6 kg (1.4-3.8), respectively. There were 3/12 patients under 2.5 kg and four patients were under 35 weeks of gestation. The most common diagnosis (7/12) was hypoplastic left heart syndrome with aortic atresia. Associated extracardiac anomalies were present in four patients. Three patients had an additional cardiac defect and two of these required an additional surgical procedure besides the stage I Norwood. The mean circulatory arrest was 56 min (46-63). ECLS was initiated preoperatively in one, intraoperatively in nine, and postoperatively in two patients. The indication for support was: arrhythmia (one), low output (six), cardiac arrest (three), unbalanced circulation (one), and hypoxemia (two). The mean duration of support was 68 h (24-192). Eight patients were weaned off support, and six were discharged home in good condition. Morbidity included sepsis in five, renal failure in five, neurologic sequelae in three, and bleeding in two. Prematurity, renal dysfunction and the initiation of ECLS outside the operating room were significantly associated with poor outcome. Residual hemodynamic effect, low birth weight and neurologic event showed a tendency towards poor outcome, but did not reach statistical significance.

CONCLUSIONS: Although the use of ECLS in patients with single ventricle physiology still carries a significant risk, prompt initiation of support can improve the outcome in a group of patients with impaired cardiopulmonary function after stage I palliation.