Preoperative Extracorporeal Membrane Oxygenation in Children With Dextro-Transposition of the Great Arteries: Extracorporeal Life Support Organization Registry Study, 2000–2022

OBJECTIVE: To describe those neonates with dextro-transposition of the great arteries (d-TGA) who undergo preoperative support with extracorporeal membrane oxygenation (ECMO) and to compare outcomes in those undergoing the arterial switch operation (ASO) on-ECMO vs. those who undergo ASO after weaning from ECMO. DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) Registry data, 2000-2022. PATIENTS: Neonates aged up to 21 days with d-TGA supported by ECMO before ASO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 100 neonates with a median (interquartile range [IQR]) age at ECMO initiation of 4 days (IQR 1-9) and median weight of 3.4 kg (IQR 3-3.7). Mortality, as opposed to survival, was associated with the following: older age at ECMO initiation (7 d [IQR 2-12] vs. 2 d [IQR 1-6], p = 0.01), lower birthweight (3.2 kg [IQR 2.8-3.7] vs. 3.5 kg [IQR 3.1-3.7], p = 0.04), longer aortic clamp time (129 min [IQR 94-191] vs. 98 min [IQR 72-121], p = 0.02), longer cardiopulmonary bypass time (326 min [IQR 217-415] vs. 174 min [IQR 137-241], p < 0.001), and longer duration of ECMO support (7 d [IQR 4-11] vs. 4 d [IQR 2-5], p < 0.001). Also, mortality, compared with survival, was associated with occurrence of any complication and the need for renal replacement therapy (both p < 0.001). Overall, 64 of 91 (70%) neonates supported with preoperative ECMO underwent ASO on ECMO. In comparison with those undergoing ASO after ECMO, these patients had more complications (53/64 [83%] vs. 16/27, p = 0.02) and had higher mortality than those weaned from ECMO preoperatively (24/64 [38%] vs. 4/27, p = 0.03). CONCLUSIONS: In the ELSO 2000-2022 cohort of neonates with d-TGA, supported with preoperative ECMO, overall mortality was 33%. Continued postoperative ECMO support was associated with worse mortality. Therefore, we wonder whether successful weaning from ECMO before ASO may be associated with improved outcomes.