We appreciate the insightful letter provided by Dr. Cuomo and colleagues1 regarding our study evaluating risk factors for mortality in infants undergoing truncus arteriosus (TA) repair requiring extracorporeal membrane oxygenation (ECMO)2. We agree that data from the Extracorporeal Life Support Organization (ELSO) is heterogenous and have cited this as a limitation in drawing definitive conclusions.
Of the 26 patients managed on ECMO prior to truncus repair, 24 were managed on VA ECMO and 2 on VV ECMO. Delayed surgical repair may lead to inadequate systemic cardiac output and excessive pulmonary blood flow as pulmonary vascular resistance falls in the newborn and necessitate ECMO cannulation. Unfortunately the ELSO database does not allow for comment of timing of surgical repair after ECMO cannulation or the pre-operative management strategies, including methods to restrict pulmonary blood flow. In this cohort, there was no difference in age between infants undergoing surgical repair of TA prior to or after ECMO cannulation. However, the age provided in the ELSO registry is that at the time of ECMO cannulation, and so it is difficult to draw definitive conclusions to either support or refute this point.
Dr. Cuomo and colleagues make valuable comments regarding the importance of surgical decision making in improving outcomes for this population. The primary focus of our paper was to evaluate outcomes for patients requiring perioperative ECMO support with TA repair. Some of the factors we identified to be associated with mortality are similar for ECMO utilization for children with other congenital heart disease3,4, and can provide insight for ECMO surveillance and patient selection for ECMO. The ELSO database unfortunately does not allow for granular data regarding surgical decision making. Thus, we are unable to comment on why a specific approach was chosen. Additionally, as cited in our limitations, lack of data regarding certain anatomic features (e.g. truncal valve integrity) limits the ability to draw inferences about the surgical results.
The experience and results of Dr. Cuomo’s group encourage important discussions regarding overall management and outcomes for neonates undergoing TA repair. Thoughtful consideration of a patient’s anatomy and physiology is required to formulate a comprehensive and timely care plan. Ideally a combination of large database studies combined with institutional experience will help guide decision-making and optimize outcomes while avoiding the need for perioperative ECMO support.
References:
- 1.Cuomo M, Dittrich S, Cesnjevar R. Mortality of ECMO because of truncus arteriosus repair: is the surgical strategy the problem? Ann Thorac Surg 2020; in press [DOI] [PubMed] [Google Scholar]
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