Impact of postcardiotomy ECMO utilization after the Norwood procedure in the United States

Background Norwood surgery is the first stage in the surgical palliation of hypoplastic left heart syndrome (HLHS) and its variants. Postcardiotomy extracorporeal membrane oxygenation (ECMO) may be required in some patients undergoing the Norwood procedure given its complexity. Methods Kids Inpatient Database (2000–2022) and National Inpatient Sample (2016–2022) datasets were used. 2284 patients underwent a Norwood procedure. The cohort was dichotomized into ECMO (EG, n = 147) and Non-ECMO (NEG, n = 2137) groups; Survivor and Nonsurvivor. Demographic and clinical characteristics were extracted. Overlap weights were used to attain covariate balance and perform overlap-weighted analysis. Results Postcardiotomy ECMO utilization was 6% (147/2284). The EG was more likely to have HLHS as compared to its variants, total anomalous pulmonary venous return, small for gestational age, congestive heart failure, and arrhythmias. Overall discharge mortality for the entire cohort is 10%. The EG experienced higher mortality compared to NEG “44% versus 8%” and higher morbidity such as cardiac arrest, pericardial complication, cardiogenic shock, respiratory complications, acute kidney injury (AKI), postoperative bleeding, sepsis and reoperation, longer length-of-stay, and higher hospital charges than NEG. ECMO utilization rose over time, peaking after 2015, while mortality progressively declined. The Midwest had the highest ECMO use (8.93%). In multivariate analysis, ECMO use and AKI were independent predictors of mortality. Conclusions Postcardiotomy ECMO utilization for the Norwood procedure remains rare, but utilization is increasing with regional variation. Postoperative AKI and ECMO utilization were independent predictors of mortality among Norwood.