The need for extracorporeal membrane oxygenation in adults undergoing congenital heart surgery: Impact and trends of utilization

IntroductIonPatients with congenital heart disease (CHD) are living longer and increasingly surviving into adulthood.[1] Currently, nearly 60% of all CHD patients are adults and recent measurements of the adult CHD (ACHD) patient population range from 1.47 to 3 per thousand.[1][2][3] The ACHD patient population is expected to continue growing until 2050.[3] As the ACHD patients age, treatments increasingly require emergency department evaluation, hospitalization, and elective or emergent surgery.[4] ACHD patients who undergo surgery require a disproportionate allocation of resources.[5] Increased resource utilization in the ACHD appears to coincide with an overall increased postoperative morbidity and mortality.[5,6] While many ACHD patients' conditions require cardiac surgery, only a small percentage of these patients require postoperative extracorporeal membrane oxygenation (ECMO) to support circulation while the heart recovers.[7] There is a paucity of data regarding postoperative ACHD patients and the need for ECMO as well as ECMO survival.[7,8] There are also limited data regarding the risk factors associated with the need for ECMO and quantification of the impact ECMO has on admission length and cost.We conducted an analysis of the Nationwide Inpatient Sample (NIS), a national administrative discharge database, with a primary aim of identifying risk factors associated with Introduction: Adults with congenital heart disease (ACHD) represent a population with unique health-care needs.Many patients require cardiac surgery, with some requiring postoperative extracorporeal membrane oxygenation (ECMO).This study aimed to identify the risk factors for the need of postoperative ECMO and characterize the impact of ECMO on admission characteristics.Methods: Data from the 2005-2012 iterations of the Nationwide Inpatient Sample were used.ACHD admissions over 18 years with a documented cardiac surgery were included.Univariate analysis was conducted to compare the characteristics between those requiring ECMO and those who did not.Regression analysis was done to identify the independent risk factors associated with ECMO and to determine the impact of ECMO on length, cost, and mortality of the admission.Results: A total of 186,829 admissions were included.Of these, 446 (0.2%) admissions required ECMO.Those with acute kidney injury, double-outlet right ventricle, or total anomalous pulmonary venous connection were more likely to require ECMO.ECMO was also significantly more utilized in patients undergoing septal defect repair, complete repair of tetralogy of Fallot, atrial switch, and heart transplant.The use of ECMO significantly increased length, cost, and mortality of stay.Overall mortality was 62.6% in the ECMO group.Conclusion: ECMO is only needed in a small proportion of postoperative ACHD patients.The use of ECMO significantly increases cost, length of stay and mortality in these patients.Improved identification of postoperative ACHD patients who are more likely to survive ECMO may facilitate improved survival and decreased resource utilization.