Cardiology in the Young (2011), 21(Suppl.

2), 101–108 r Cambridge University Press, 2011

doi:10.1017/S1047951111001673

Original Article

Resuscitation and Extracorporeal Life Support during

Cardiopulmonary Resuscitation following the Norwood
(Stage 1) operation
Heidi J. Dalton,1 Dawn Tucker2
1
Division Chief and Professor of Child Health, Phoenix Children’s Hospital and University of Arizona College of
Medicine, Phoenix; 2Children’s Mercy Hospitals and Clinics, Kansas City, Missouri, United States of America

Abstract The success of extracorporeal support in providing cardiopulmonary support for a variety of patients has
led to use of Extracorporeal Life Support, also known as ECLS, as a rescue for patients failing conventional
resuscitation. The use of Extracorporeal Life Support in circumstances of cardiac arrest has come to be termed
‘‘Extracorporeal Life Support during Cardiopulmonary Resuscitation’’ or ‘‘ECPR’’. Although Extracorporeal Life
Support during Cardiopulmonary Resuscitation was originally described in patients following repair of congenital
cardiac defects who suffered a sudden arrest, it has now been used in a variety of circumstances for patients both
with and without primary cardiac disease. Multiple centres have reported successful use of Extracorporeal
Life Support during Cardiopulmonary Resuscitation in adults and children. However, because of the cost, the
complexity of the technique, and the resources required, Extracorporeal Life Support during Cardiopulmonary
Resuscitation is not offered in all centres for paediatric patients with refractory cardiac arrest. The increasing success
and availability of Extracorporeal Life Support during Cardiopulmonary Resuscitation in post-operative cardiac
patients, coupled with the fact that patients undergoing the Norwood (Stage 1) operation can have rapid,
unpredictable cardiac deterioration and arrest, has led to a steady increase in the use of Extracorporeal Life Support
during Cardiopulmonary Resuscitation in this population. For Extracorporeal Life Support during Cardio-
pulmonary Resuscitation to be most successful, it must be deployed rapidly while the patient is undergoing
excellent cardiopulmonary resuscitation. Early activation of the team that will perform cannulation could possibly
shorten the duration of cardiopulmonary resuscitation and might improve survival and outcome. More research
needs to be done to refine the populations and circumstances that offer the best outcome with Extracorporeal
Life Support during Cardiopulmonary Resuscitation, to evaluate the ratios of cost to benefit, and establish the
long-term neurodevelopmental outcomes in survivors.

Keywords: Extracorporeal membrane oxygenation; paediatrics; congenital cardiac defect; hypoplastic left heart syndrome; Norwood

The use of Extracorporeal Life Support in circum-

T
HE SUCCESS OF EXTRACORPOREAL SUPPORT IN
providing cardiopulmonary support for a
variety of patients has led to the use of
Extracorporeal Life Support, also known as ECLS, as
a rescue for patients failing conventional resuscitation.
Correspondence to: Dr H. J. Dalton, MD, FCCM, Division Chief and Professor
of Child Health, Phoenix Children’s Hospital and University of Arizona College
of Medicine,, Phoenix, Arizona, United States of America. Tel: 11 602 546
1784; Fax: 11 602 546 1785; E-mail: hdalton@phoenixchildrens.com
stances of cardiac arrest has come to be termed
‘‘Extracorporeal Life Support during Cardiopulmonary
Resuscitation’’ or ‘‘ECPR’’.1,2 Although Extracorporeal
Life Support during Cardiopulmonary Resuscita-
tion was originally described in patients following
repair of congenital cardiac defects who suffered a
sudden arrest, it has now been used in a variety of
circumstances for patients both with and without
primary cardiac disease.3–5 Multiple centres have
102 Cardiology in the Young: Volume 21 Supplement 2
Table 1. Selected outcomes from Extracorporeal Life Support during Cardiopulmonary Resuscitation.
Author/year/reference Number of
number Patient population patients
Dalton et al, 19931 Cardiac 29
Del Nido et al, 19923 Post-cardiotomy 11
Morris et al, 20045 Cardiac and non-cardiac 64
Thiagarajan et al, 20076 ELSO registry 682
Prodhan et al, 200923 Mixed 32
Raymond et al, 20094 NRCPR registry 199
Alsoufi et al, 200924 ICU 80
Sivarajan et al, 201129 Cardiac 39
ELSO 5 Extracorporeal Life Support Organisation; NRCPR 5 National Registry Cardiopulmonary Resuscitation; ICU 5 intensive care unit
reported successful use of Extracorporeal Life Support
during Cardiopulmonary Resuscitation in adults and
children.6 However, because of the cost, the complex-
ity of the technique, and the resources required,
Extracorporeal Life Support during Cardiopulmonary
Resuscitation is not offered in all centres for paediatric
patients with refractory cardiac arrest. The increasing
role of Extracorporeal Life Support during Cardio-
pulmonary Resuscitation in resuscitation, however, is
highlighted by recommendations from groups such as
that of the American Heart Association, which state:
yTo consider extracorporeal CPR for in-hospital cardiac
arrest refractory to initial resuscitation attempts if the
condition leading to cardiac arrest is reversible or
amenable to heart transplantation, if excellent conven-
tional CPR has been performed after no more than
several minutes of no-flow cardiac arrest, and if the
institution is able to rapidly perform extracorporeal
membrane oxygenation.7
Table 1 shows a summary of published literature
regarding paediatric extracorporeal cardiopulmonary
resuscitation. Most of the patients in these series were
cardiac patients with rates of survival to discharge of
30–70%. Duration of cardiopulmonary resuscitation
before Extracorporeal Life Support ranged from 4 to
127 minutes. One large paediatric study has shown
that good outcome can be achieved when extracorporeal
cardiopulmonary resuscitation is started after 30–90
minutes of refractory standard cardiopulmonary resus-
citation for cardiac arrests occurring in the hospital.5
The success of Extracorporeal Life Support in
patients who suffer cardiac arrest following con-
genital cardiac surgery has led to expansion of this
technology to patients who were previously con-
sidered poor candidates. Patients who have under-
gone the Norwood (Stage 1) operation fall into this
category. Although there are a few reports of
Extracorporeal Life Support being applied routinely
2011
Percentage Duration of cardiopulmonary
survival (%) resuscitation (minutes; median/range)
55 42 (42–100)
64 65
33 50 (5–105)
38 Not reported
73 Survivors 43 (15–142)
Non-survivors 60 (20–76)
44 Survivors 46 (28–68)
Non-survivors 57 (38–71)
34 43 (14–110)
38 Survivors 15
Non-survivors 40
following the Norwood (Stage 1) operation to
prevent the sudden cardiac deterioration often noted
in these patients, this strategy has not become an
accepted practice in most centres.8,9 Conversely,
many early reports of Extracorporeal Life Support
applied to patients with functionally univentricular
hearts had poor survival, which led to exclusion of
Extracorporeal Life Support in these patients in
some centres. However, the increasing success and
availability of Extracorporeal Life Support during
Cardiopulmonary Resuscitation in post-operative
cardiac patients, coupled with the fact that patients
undergoing the Norwood (Stage 1) operation can
have rapid, unpredictable cardiac deterioration and
arrest, has led to a steady increase in the use of
Extracorporeal Life Support during Cardiopulmon-
ary Resuscitation in this population. Although the
goal of applying Extracorporeal Life Support is to
initiate support before arrest, correct identification
of patients likely to suffer a cardiac arrest has proven
difficult. Once the decision to place a patient with a
functionally univentricular heart on Extracorporeal
Life Support is made, these patients pose special
considerations for care and management.
Indications for initiating Extracorporeal Life
Support
The decision to initiate Extracorporeal Life Support
varies by institutional practice for patients with
functionally univentricular hearts. The presence of
low cardiac output, systolic or diastolic dysfunction,
uncontrolled arrhythmia, and/or cardiac arrest are
common aetiologies.10,11 Often, in patients with
functionally univentricular hearts, an increased ratio
of the flow of blood in the pulmonary circulation in
comparison with the systemic circulation – Qp/Qs
ratio – is a common cause for low cardiac output and
manifests as elevated level of lactate in the serum and
 Dalton and Tucker: ECMO and HLHS
increased arteriovenous oxygen saturation difference.12
Serial elevation of levels of lactate in the serum despite
maximal medical therapies has been suggested as an
indication for elective institution of Extracorporeal
Life Support.13 Other clinicians have noted that
dosage of vasoactive agents, such as epinephrine,
may be triggers for initiating Extracorporeal Life
Support, although no specific dose has been identified.
In a similar vein, the ‘‘vasoactive inotrope score’’ has
also been suggested as related to both the need for
Extracorporeal Life Support and the outcome after
such support:14–16
ðVIS Þ ¼ dopamine þ dobutamine þ ðepinephrine  100Þ
þ ðmilrinone  10Þ þ ðvasopressin  10; 000Þ:
In the above equation dosage as micrograms per
kilogram per minute except vasopressin is expressed
as units per kilogram per minute.
After failed attempts to improve cardiac output
and maintain balance of transport of oxygen,
Extracorporeal Life Support may be initiated.17
The fact that clinical examination and vital signs
also give information that can be important must
not be overlooked. Capillary refill time, urine
output, mental awareness, activity, and respiratory
examination can give important clues. Persistent
tachycardia or bradycardia, temperature – especially
the difference between core and peripheral tempera-
ture, and systemic arterial pressure are all important
parameters when assessing the cardiac output and
overall condition of the patient. Patients with
functionally univentricular hearts, especially those
who have undergone the Norwood (Stage 1) operation
with a modified Blalock–Taussig shunt, may have low
diastolic systemic arterial pressure from run-off into
the aortopulmonary shunt and the pulmonary circula-
tion. Extremely low diastolic pressures can lead to
coronary arterial ischaemia and poor myocardial
perfusion. Assurance of optimal balance of transport
of oxygen includes continual balancing of two
parallel circulations. Goals should be aimed to
maintain normal arteriovenous oxygen saturation
difference with systemic oxygenation levels appro-
priate for a patient dependent on an aortopulmonary
shunt, usually greater than 70% arterial saturation.
Care of patients with a functionally
univentricular heart on Extracorporeal
Life Support
The majority of patients receiving Extracorporeal
Life Support after the Norwood (Stage 1) operation
are cannulated via the venoarterial route, often
through a reopened mediastinum with cannulas
103
placed directly into the right atrium and aorta.
Although there is some logic to venovenous
Extracorporeal Life Support being sufficient in cases
of hypoxia, with improved systemic oxygenation
allowing improvement in cardiac and respiratory
function sufficient to support the patient, this
strategy is not a common practice. In patients with
venoarterial cannulation who have an aortopulmon-
ary shunt, most institutions favour leaving the
shunt open during Extracorporeal Life Support, as
several early reports found poor survival when the
shunt was closed, and more recent studies demon-
strated improved survival when the shunt is left
open.18 Patients with open aortopulmonary shunts
frequently require increased flow of blood to
support both the pulmonary and the systemic
circulations, often greater than 150–200 millilitres
per kilogram per minute, secondary to the
significant run-off into the aortopulmonary shunt
and the pulmonary circulation. Excessive flow of
blood into the pulmonary circulation can lead to
pulmonary oedema and elevated pulmonary pres-
sures, and thus some patients – estimates are as high
as 40% – may require restriction of flow into the
shunt via a clip or suture ligature during
Extracorporeal Life Support. Manoeuvres to main-
tain elevated pulmonary vascular resistance to limit
flow of blood into the pulmonary circulation have
also been described. Patients who receive a right
ventricular to pulmonary arterial conduit – Sano
modification – require rates of flow similar to
patients with biventricular circulation. Owing to
the fact that many patients after the Norwood
(Stage 1) operation suffer only problems with
cardiac output and have good pulmonary exchange
of gases, elimination of the oxygenator from the
Extracorporeal Life Support circuit has been done to
provide ventricular support without supporting
exchange of gases.19 This approach is colloquially
termed ‘‘ECMO-lite’’ or ‘‘NOMO’’ – no-oxygenator
membrane oxygenation. This adaptation may
reduce the amount of heparin necessary, as heparin
is not required to prevent the oxygenator from
thrombosing, although there are no studies that
have shown great benefit or risk from elimination of
the oxygenator. It is likely that newer ‘‘hollow-fibre
devices’’ may require less heparin than the ‘‘silicone
membrane lung’’ and thus decrease the complica-
tions related to bleeding often seen in these post-
operative patients, but these reports are small and
few.20 Along with new technology in oxygenators,
new centrifugal pumps are also now available for
Extracorporeal Life Support. These systems often are
more compact, require less priming volume, and
can be implemented within several minutes. Their
active venous ‘‘suction’’ action decreases the need for
104 Cardiology in the Young: Volume 21 Supplement 2
drainage dependent on gravity and allows reduction
in the length of the circuit, which may also lessen
the need for heparin, induce less inflammatory
response, and diminish exposure to blood used for
priming. Despite the fact that use of centrifugal
pumps with ‘‘hollow-fibre oxygenators’’ is currently
popular and seems to offer some advantages, they
are dependent on adequate preload and sensitive to
afterload for forward flow. Understanding differ-
ences between systems using the traditional roller-
pump and systems using the centrifugal pump is
paramount to providing optimal care for the
patient. Another aspect of care for patients after
the Norwood (Stage 1) operation is to remember
that the large intra-atrial communications present
leave them at excessively high risk for neurological
or cardiac – coronary – injury from emboli of air.
Prevention of entrainment of air into the Extra-
corporeal Life Support circuit and prevention of air
reaching the patient is crucial. Owing to the fact
that centrifugal pumps, as well as roller head
devices, can generate extremely high negative
pressures on the venous side of the circuit, most
centres have monitoring and alarm limits set for
decreasing flow or stopping the pump if the limit
for negative pressure is reached. Maintaining some
type of venous reservoir is also helpful to avoid large
swings of negative pressure and associated haemo-
lysis. Ventilatory strategies include placing patients
on ‘‘resting’’ ventilatory support with
> a low rate, that is, less than 10 breaths per minute,
> high positive end expiratory pressure to maintain
some lung inflation, that is, 8–15 centimetres of
water, and
> 21% inspired oxygen.
‘‘Sweep flow’’ and adjustment of delivery of inspired
oxygen (FiO2) are used for normalising parameters on
the blood gas. Owing to the fact that the lungs of these
patients are often healthy, reducing mechanical venti-
latory support to the level of extubation is physiolo-
gically possible but is rarely done in practice. Having
control of the airway in the event of malfunction of the
circuit and need for emergent separation from the
Extracorporeal Life Support circuit is seen as worth the
associated risks of continued intubation.
A few practical points regarding care of cardiac
patients are to pay close attention to normalisation
of the function of organs and the acid–base balance
once Extracorporeal Life Support has begun. Several
reports have outlined the fact that failure to
normalise levels of lactate, acidosis, or renal or
hepatic insufficiency by 24 hours after institution of
support are all associated with poor outcome.4,14
The amount of blood products consumed has also
been linked to outcome.11 In hypothermic patients,
2011
following clinical examination for adequacy of
support is difficult, as these patients are often
peripherally vasoconstricted and with poor colour of
the skin. Following adjunct measures such as those
discussed above, as well as other parameters such as
mixed venous saturations and urine output, are all
helpful during Extracorporeal Life Support. It is of
paramount importance to assess neurological func-
tion following arrest. This assessment may best be
accomplished by clinical examination, eliminating
sedation or neuromuscular blockade until neurolo-
gical activity such as movement of the patient can
be assessed. Other measures such as electroencepha-
lographic monitoring, computerised axial tomogra-
phy scan, cranial ultrasonography, and evoked
potentials are additional methods to monitor the
condition and function of the brain non-invasively.
Although monitoring with near-infrared regional
spectroscopy is currently used in many centres, the
true reliability of these monitors in assessing
cerebral and somatic flow of blood and long-term
neurological outcome is unknown.21,22
Although there are no paediatric studies that
demonstrate the effectiveness of hypothermia after
cardiac arrest in improving outcome, the current
trend is to maintain the core body temperature of
the patient between 33 and 35 degrees centigrade
for 24–48 hours. A randomised trial of hypothermia
versus normothermia after cardiac arrest is in
progress, and the results of this trial are eagerly
awaited. Unfortunately, this trial will not be
completed for several years, and thus conventional
wisdom will have to guide decisions about the care
of the patient in the meantime. One issue, on which
clinicians agree even now, however, is that prevent-
ing fever following arrest is optimal, and this goal
can be easily obtained with temperature control by
the Extracorporeal Life Support circuit.
Failure of cardiac function to return within 72
hours of cannulation has been associated with poor
outcome in post-cardiotomy patients.23–25 Although
function may not have returned to a level to allow
separation from the Extracorporeal Life Support
circuit, a continuous improvement in cardiac function
and the function of the other organs should be
observed after successful Extracorporeal Life Support
during Cardiopulmonary Resuscitation. Cardiac cathe-
terisation should be strongly considered if cardiac
function does not return quickly to identify any
residual lesions, which can be repaired either surgically
or with transcatheter interventions. ‘‘Myocardial stun-
ning’’, which is the term given for asystole or minimal
contractility noted following initiation of Extracorpor-
eal Life Support, is often seen in the first few hours
following initiation of venoarterial extracorporeal
membrane oxygenation for Extracorporeal Life
 Dalton and Tucker: ECMO and HLHS
Support during Cardiopulmonary Resuscitation.
Although the exact aetiology of this myocardial
stunning is unknown, it may relate to changes in the
cellular concentration of calcium, and thus maintain-
ing normal levels of ionised calcium is important, or
from the sudden increased ventricular afterload and
decreased ventricular preload that occurs with venoar-
terial extracorporeal membrane oxygenation. Although
this condition seems to be self-limited in many
patients, others respond to cardiac pacing and/or
vasoactive manipulations including reduction of after-
load with milrinone or nitroprusside. Although not
necessary in patients with functionally univentricular
hearts with open atrial communications, emergent left
atrial decompression by septostomy or left atrial
cannulation may be required in patients with
biventricular circulation with acute left heart failure
on Extracorporeal Life Support. The inability for
the aortic valve to open and eject blood may lead to
left atrial hypertension, pulmonary venous conges-
tion, and pulmonary haemorrhage. Maintaining the
intra-cardiac filling pressures at low levels to augment
endocardial flow of blood is also an important
component of cardiac recovery.
Although renal insufficiency or renal failure
requiring renal replacement therapy or filtration
to maintain balance of fluids is frequent in patients
who undergo Extracorporeal Life Support during
Cardiopulmonary Resuscitation, it should be re-
membered that renal failure and use of dialysis has
been associated with worse outcome in most
reports.26 The lack of pulsatility during venoarterial
Extracorporeal Life Support may be one factor that
contributes to the development of renal insuffi-
ciency, although again no specific aetiology other
than a proposed period of poor perfusion to the
kidneys has been identified as the ultimate cause of
renal disease during Extracorporeal Life Support.
Prognostic features and outcome
Predictive markers are important to identify appropriate
candidates for Extracorporeal Life Support during
Cardiopulmonary Resuscitation and provide prognostic
information. Common independent factors reported in
the literature associated with failure to wean off
Extracorporeal Life Support are
> prolonged duration of Extracorporeal Life Support,
> elevated levels of lactate in the serum,
> renal failure,
> multi-organ failure, and
> functionally single ventricle.
Importantly, findings are often variable between
published reports, and thus no concrete recommen-
dations for candidacy or outcome can be determined.
105
A recent report11 identified specific factors associated
with failure to wean off Extracorporeal Life Support as
> duration of greater than 10 days of support with
Extracorporeal Life Support,
> urine output less than 2 millilitres per kilogram
per hour in the first 24 hours of initiation of
Extracorporeal Life Support,
> renal failure, and
> pH less than 7.35 after 24 hours of Extracorpor-
eal Life Support.
Poor outcomes are also associated with low
regional cerebral oxygen saturations by near-infrared
regional spectroscopy in the first 48 hours after the
Norwood (Stage 1) operation.12 A recent report27
described an institution that developed specific cut-
points where mortality greatly increased. Patients
with the following findings had a higher mortality
than patients with lower scores:
> adjusted anion gap (AGc) value greater than 23
milliequivalents per litre,
> a first venoarterial carbon dioxide gradient (p[v-
a]CO2) value greater than 16, and
> a first viability index (AGc 1 p[v-a]CO2) greater
than 28.
Following the variables discussed above and paying
careful attention to optimising care while on Extra-
corporeal Life Support to reverse findings such as
acidosis, serial elevations of lactate, and others, may
have a beneficial effect on ultimate outcome.
Cardiac recovery on Extracorporeal Life Support is
assessed during reduction of flow from the Extra-
corporeal Life Support circuit. The following variables
at low flow often indicate that the patient is ready for a
trial off the Extracorporeal Life Support circuit:
> adequate haemodynamics with good perfusion,
> low levels of lactate,
> satisfactory near-infrared regional spectroscopy,
> satisfactory mixed venous levels of oxygen or
mixed venous oxygen saturation (SVO2).
Echocardiographic assessment of cardiac perfor-
mance is often helpful during this period to assess
contractility and valvar integrity. If the patient is
able to maintain adequate haemodynamics, often
with need for some vasoactive support, and exchange
of gases after a trial period off Extracorporeal Life
Support, removal of the cannulas can be performed.
The sternum is often left ‘‘open’’ and covered with a
silastic patch for 24–48 hours following separation
from Extracorporeal Life Support to ensure that stable
cardiac recovery has occurred.
More detailed data about outcomes of cardiac
patients who receive Extracorporeal Life Support are
provided elsewhere in this Supplement to Cardiology
106 Cardiology in the Young: Volume 21 Supplement 2
in the Young. A few studies have focused specifically
on outcomes of patients with functionally univentri-
cular hearts requiring Extracorporeal Life Support
during Cardiopulmonary Resuscitation. The most
recent of these noted that 14 out of 20 patients with
functional single ventricles received Extracorporeal Life
Support during active Cardiopulmonary Resuscita-
tion.14 Of these 14 patients, 79% were weaned off
Extracorporeal Life Support and 57% survived to
discharge. Interval follow-up, median 11 months, at 1,
3, 6, and 12 months found freedom from death or
cardiac transplantation in 57%, 50%, 43%, and 36%,
respectively. When risk factors for survival were
assessed, no difference in duration of cardiopulmonary
resuscitation between survivors and non-survivors was
noted (39 versus 42 minutes, p 5 0.12). Survivors had
significantly shorter duration of Extracorporeal Life
Support (4 versus 8 days, p 5 0.002). Of variables
assessed prior, during, and after Extracorporeal Life
Support during Cardiopulmonary Resuscitation was
initiated, peak levels of lactate in the serum within the
first 24 hours of Extracorporeal Life Support
(p 5 0.03) and duration of Extracorporeal Life Support
(p 5 0.02) proved significant between survivors and
non-survivors. Further analysis noted that a level of
lactate at 24 hours of 8.9 millimoles per litre was the
best predictor for survival, with the area under the
receiver operating characteristic curve, also known as
the C-index, of 0.87, sensitivity of 87%, and
specificity of 99%. Other points of note from this
review of data at a single centre found that equivalent
numbers of patients required Extracorporeal Life
Support during Cardiopulmonary Resuscitation dur-
ing the day, defined as 7 am to 6 pm, during the
weeknights, defined as 7 pm to 6 am, or weekends,
with no difference in survival based on time of day. All
but two patients received Extracorporeal Life Support
during Cardiopulmonary Resuscitation after arrest in
the cardiac intensive care unit, and transthoracic
cannulation was performed in 13 out of 14 patients.
Aetiologies for arrest were primary cardiac in 86% of
patients and respiratory failure leading to cardiac arrest
in 14% of patients. Complications and findings after
Extracorporeal Life Support between survivors and
non-survivors were not significantly different. Mortal-
ity was due to
> multi-organ failure (29%, n 5 4),
> sepsis or necrotising enterocolitis (36%, n 5 5),
> cerebral haemorrhage (14%, n 5 2), and
> failure of myocardial recovery (7%, n 5 1).
Type of repair (Norwood, Damus–Kaye–Stansel
procedure; creation of AP anastomosis without arch
reconstruction; Sano modification, Blalock–Taussig
shunt) was not associated with outcome, although
categorical numbers were small. Of the two patients
2011
with associated genetic or chromosomal anomalies,
weaning off Extracorporeal Life Support was obtained
but neither survived to discharge. Approximately
50% of non-survivors had no improvement in
ventricular function after 48 hours of Extracorporeal
Life Support, whereas 50% of survivors demonstrated
echocardiographic evidence of ventricular improve-
ment, although this was not a statistical factor in
overall outcome. Specific neurological outcome was
not evaluated, although it is stated that survivors were
‘‘neurologically intact’’ at follow-up. One intriguing
editorial comment that accompanied this report was
related to the impact of elevated lactate on survival. Of
four patients with a Blalock–Taussig shunt, an ‘‘open-
shunt’’ approach with larger venous cannulas for
increased drainage and flow on Extracorporeal Life
Support was practiced. Whether run-off into the
aortopulmonary shunt and the pulmonary circulation
led to excessive pulmonary blood flow and decreased
systemic perfusion is not able to be assessed, but it is a
factor to keep in mind. It is estimated by others that
approximately 40% of patients with Blalock–Taussig
shunts receive some type of restriction to flow during
Extracorporeal Life Support because of this concern.
Similar to other studies, the inability to achieve
reduction of serial levels of lactate following initiation
of Extracorporeal Life Support was associated with
poor outcome. Whether this relates to the extent of
hypoperfusion before Extracorporeal Life Support,
inadequate cardiopulmonary resuscitation during in-
itiation of Extracorporeal Life Support, or problems in
delivery of oxygen during Extracorporeal Life Support
has not been determined. It does, however, reflect the
need for vigilance in care once Extracorporeal Life
Support is deployed to achieve several related
objectives:
> optimise delivery of oxygen,
> reduce production of lactate, and
> maximise clearance of lactate.
Failure to achieve these goals may prove to be a
useful marker and predictor of short- and long-term
morbidity and mortality.
One final note regarding Extracorporeal Life
Support during Cardiopulmonary Resuscitation re-
lates to cost. Although data on this topic are scarce,
one summary of 32 patients receiving Extracorporeal
Life Support for arrest (n 5 18) or post-operative
cardiac failure (n 5 14) examined the financial
impact of these patients.28 Congenital cardiac disease
was present in 84% of patients. Survival to discharge
was 47% in this study, although 50% were
successfully weaned off Extracorporeal Life Support.
The average duration of Extracorporeal Life Support
was 5.1 plus or minus 4 days. Approximately, 44%
of patients had the physiology of a functionally
 Dalton and Tucker: ECMO and HLHS
univentricular heart. The majority of deaths were
related to multi-organ failure and occurred while
receiving Extracorporeal Life Support or within
72 hours of decannulation. Approximately 31%
(7 out of 32) of patients had significant neurological
events, with three survivors noted to have gross
motor weakness on discharge and two with sig-
nificant cognitive impairment. The median hospital
cost for Extracorporeal Life Support per patient was
$156,324.00 (United States of America dollars),
although there was wide variation in costs even
among survivors ($81,413–1,238,004). The mean
cost of Extracorporeal Life Support per hour was
estimated at $16,430.00 plus or minus $6901.
Follow-up costs in terms of the predicted need for
additional surgical procedures, medications, and
follow-up by physicians were also included in the
overall economic analysis. Parents were asked to
complete a ‘‘Health Utilities Analysis’’ questionnaire,
which ranges from 0.1 to 1.0 in scale, with 1.0
described as full health. The mean score for survivors
of Extracorporeal Life Support was 0.75 plus or
minus 0.19. Using standard survival scales for
patients with congenital cardiac disease and patients
and functionally univentricular hearts, estimation of
quality life-year saved was calculated. Overall range
of cost utility was between $20,687 and $32,220,
with a median of $24,386 per quality life-year saved.
Accepted cost efficacy is described as procedures that
result in less than $50,000 per quality-adjusted life-
year saved. Although this report is from a single centre,
future collaborations may continue to give ongoing
evaluation of the economic impact of extracorporeal
support in patients with cardiac disease.
Summary
Extracorporeal Life Support during Cardiopulmonary
Resuscitation has been successfully used to rescue
many patients with refractory cardiac arrest with
short-term good neurological outcomes, including
patients with hypoplastic left heart syndrome. To truly
have a system of Extracorporeal Life Support during
Cardiopulmonary Resuscitation, all required personnel
should be available in-house 24 hours per day, 7 days
per week. However, if this is not possible, a system
that gets required surgical and supportive personnel to
the bedside in a matter of minutes is needed. For
Extracorporeal Life Support during Cardiopulmonary
Resuscitation to be most successful, it must be
deployed rapidly while the patient is undergoing
excellent cardiopulmonary resuscitation. Early activa-
tion of the team that will perform cannulation could
possibly shorten the duration of cardiopulmonary
resuscitation and might improve survival and out-
come.29 More research needs to be done to refine the
107
populations and circumstances that offer the best
outcome with Extracorporeal Life Support during
Cardiopulmonary Resuscitation, evaluate the ratios of
cost to benefit, and establish the long-term neurode-
velopmental outcomes in survivors. Variability in
techniques of the care of patients from centre to centre,
equipment used, and protocols followed also make it
difficult to extrapolate the experience of one centre to
others. By collaboration and even attempting to
standardise how Extracorporeal Life Support during
Cardiopulmonary Resuscitation is performed, needed
information as to the optimal means of providing
support will be obtained.
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