To investigate the outcomes of pediatric patients requiring extracorporeal membrane oxygenation (ECMO) after the Fontan operation.

We conducted a retrospective cohort analysis of the Extracorporeal Life Support Organization registry, including patients <18 years who underwent ECMO after Fontan palliation from 2010 to 2023. Patients undergoing a first ECMO run during their hospitalization for Fontan surgery were included.

Among 281 children undergoing ECMO after Fontan palliation, survival at hospital discharge was 48.4%. Median age and weight were 3.9 years (interquartile range [IQR], 2.7-5.5) and 15 kg (IQR, 12-19), respectively. Venoarterial ECMO was used in 92% of patients, multiple drainage cannulas in 21%, central cannulation in 49%, and Fontan pathway decompression in 51%. Survival did not differ according to the use of multiple drainage cannulas or decompression strategy. Independent predictors of hospital mortality included pre-ECMO arrest (odds ratio [OR], 1.88; P = .042), pre-ECMO bicarbonate administration (OR, 2.01; P = .019), higher ECMO flow at 4 hours (OR, 1.01; P = .014), longer ECMO duration (OR, 1.09; P = .002), longer admission-to-cannulation time (OR, 1.04; P = .002), and neurologic (OR, 5.99; P < .001), renal (OR, 2.92; P = .005), or pulmonary complications (OR, 13.07; P = .022). Eight patients were transitioned to ventricular assist device support after ECMO, and 6 underwent heart transplantation; survival in both groups was 50%.

Hospital survival after ECMO following Fontan palliation has improved compared with prior reports. The avoidance of pre-ECMO arrest and earlier cannulation are potentially modifiable factors that may improve outcomes for these patients. Prospective studies are warranted to better define the timing, outcomes, and optimal support strategies in this population.