Outcomes after extracorporeal membrane oxygenation following the norwood procedure: a systematic review and meta-analysis

BACKGROUND: Survival following the Norwood procedure has improved substantially, but outcomes for the high-risk subgroup requiring postoperative extracorporeal membrane oxygenation (ECMO) remain unclear. We explored short- and intermediate-term outcomes in these neonates. MAIN BODY: We systematically searched PubMed, EMBASE, Cochrane Central and Web of Science (final search: 25 February 2025). Comparative studies reporting outcomes for patients with versus without postoperative ECMO were included. Primary outcomes were short-term mortality, secondary outcomes included stages-2-and-3 palliation completion, operative times, recovery parameters, and complications. Statistical analysis used RevMan 5.4 to calculate pooled risk ratio (RR), odds ratios (OR) or mean differences (MD) with 95% confidence intervals employing random-effects models; heterogeneity was assessed using I² statistics and Cochran's Q test. Eight studies (2,612 patients: 15% with ECMO) were included. In-hospital mortality was five times greater in the ECMO group (RR = 5.53, CI = 4.41-6.93, p = 0.0003), though survival to Glenn and Fontan completion were comparable. Cardiopulmonary bypass duration was significantly longer in the ECMO group (MD = 28.07 min, CI = 18.19-37.95, p = 0.0004). Postoperative ICU recovery was significantly prolonged for ECMO patients (MD = 10.56 days, CI = 1.28-19.83, p = 0.03), though hospital recovery was similar. Postoperative atrioventricular valve regurgitation, Norwood reoperation, delayed chest closure, unplanned reoperation or death/transplantation were comparable. Risk of bias (ROBINS-I) was formally assessed. CONCLUSION: Our analysis supports that ECMO use post-Norwood procedure identifies a high-risk subgroup with significantly higher early-mortality and resource utilisation. However, this association must be interpreted cautiously due to heterogenous ECMO indications. Future efforts should focus on identifying modifiable risk factors to improve outcomes.