To describe the incidence and survival of extracorporeal membrane oxygenation (ECMO) deployment in the operating room (OR) for failure to wean from cardiopulmonary bypass (CPB) after surgery for congenital heart disease (CHD).

Retrospective, quaternary children’s hospital.

Children supported with ECMO in the OR after cardiac surgery during the 2000 to 2023 period.

In total, 123 children (0.8% of cardiac surgical cases in the study period) had ECMO initiated in the OR. Children supported with ECMO in the OR had a median age of 1.6 months (interquartile range [IQR], 0.2-10.0) and underwent complex cardiac surgery (Risk Adjustment in Cardiac Surgery 1, categories 3-6 [N = 108; 88%]). Seventy-seven patients (63%) had 2-ventricle circulation, 38 patients (31%) had single-ventricle circulation, and 8 (5%) patients had cavopulmonary circulation. The median CPB time was 253 minutes (IQR, 188-348) with an aortic cross-clamp time of 109 minutes (IQR, 71-172). ECMO duration for all patients was 5 days (IQR, 3-9). Sixty-one patients (50%) underwent cardiac catheterization, and 41 patients (34%) required surgery while on ECMO. Bleeding was common in all patients on ECMO. There were cardiac complications in 21% and neurologic complications in 24%. Eleven patients (9%) needed a heart transplant or transition to a ventricular assist device. Fifty-five (45%) of the patients survived to discharge.

While ECMO continues to be a life-saving intervention, children requiring ECMO in the OR after cardiac surgery for CHD face high mortality. The need for prolonged ECMO support, suggesting irreversible myocardial failure and neurologic injury, is associated with increased mortality.