Extracorporeal Membrane Oxygenation in Pediatric Pulmonary Hypertension: A Single-Center Cohort to Inform Decision-Making

Limited data describe children with pulmonary hypertension (PH) supported on extracorporeal membrane oxygenation (ECMO). This retrospective study (2017-2023), including children less than 18 years with PH at a quaternary institution, identified associations with 1) mortality in ECMO-supported patients, 2) extracorporeal cardiopulmonary resuscitation (ECPR), and 3) inpatient death without ECMO (DWE). Among 113 children with PH supported on ECMO, the median age was 31 days (interquartile range [IQR]: 1-332), mortality was 41%, with 19% requiring ECPR. Lung disease was the most common PH-subgroup (52%). In multivariable models including pre-cannulation factors, ECPR (adjusted odds ratios [aOR]: 4.9 [1.4-17.2]) and pulmonary vein stenosis (PVS) (aOR: 7.5 [1.1-51.4]) were associated with mortality. After adding post-cannulation factors, ECPR (aOR: 9.41 [2.21-40.12]), PVS (aOR: 8.07 [1.05-61.93]), and longer ECMO duration (aOR: 3.21 [1.41-9.90]) were independently associated with mortality. Extracorporeal cardiopulmonary resuscitation was associated with cardiac intensive care unit (CICU) admission (OR: 11.7 [3.2-42.5]), single-ventricle physiology (OR: 6.6 [2.3-18.5]), and left heart disease PH-subgroup (OR: 8.9 [3.1-25.6]). Compared to ECMO-supported patients, DWE patients (n = 75) were older and more likely to have a tracheostomy, had lower pulmonary artery pressures, received fewer PH medications, and differed in PH-subgroup. While ECPR and PVS confer increased mortality risk in children with PH requiring ECMO, survival remains achievable. Incorporating patient-level data into prognostic frameworks may support individualized approaches to ECMO decision-making in this cohort.