Neonatal Conditions Safety of delayed decannulation of venoarterial cannulas in patients with congenital diaphragmatic hernia ☆ Mercedes Pilkington, George B. Mychaliska, Marcus D. Jarboe, Meghan A. Arnold, Ronald B. Hirschl, Samir K. Gadepalli ⁎ Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI abstract article info Article history: Received 6 September 2019 Accepted 29 September 2019 Key words: CDH ECMO Decannulation Cannulation ECLS Venoarterial Background: The practice of “cutting-away” from venoarterial extracorporeal life support (ECLS) and leaving in- dwelling heparinized cannulas prior to decannulation is controversial. This study aims to determine the safety and efficacy of this strategy in patients with congenital diaphragmatic hernia (CDH) who require ECLS. Methods: A single-center retrospective review of electronic health records was performed on all patients with CDH who underwent elective ECLS decannulation between January 2014 and September 2018. Descriptive sta- tistics are presented as medians with interquartile range. Results: Seventy-three percent (19/26) of patients who underwent venoarterial ECLS for CDH were electively decannulated. After a median ECLS run of 10.7 days [6.1–19.5], patients were “cut-away” for a median of 26 h [19.8–43] prior to decannulation. One patient required re-initiation at 36 h for a pulmonary hypertensive crisis (5%). There were no major bleeding or embolic events while “cut-away”, and four (21%) patients had clots removed from the cannulas without clinical sequelae. One patient was recannulated 16 days following initial decannulation. Conclusions: Our data suggests that “cutting-away” from ECLS in patients with congenital diaphragmatic hernia is safe and allows a period of observation without significant complications. This strategy may be particularly helpful in patients at risk for recannulation, but better prognostic criteria are needed. Level of Evidence: Level IV. Type of Study: Treatment Study. © 2019 Elsevier Inc. All rights reserved. Venoarterial (VA) cannulation is the most common method used for cannulation for extracorporeal life support (ECLS) [1]. As opposed to venovenous (VV) ECLS, weaning patients from VA support requires direct clamping of the circuit; therefore, a limited time (generally less than 4 h) is available to determine readiness for decannulation. Many providers may prefer a longer period of observation to predict successful removal from ECLS in high risk patients; for example, those with congenital dia- phragmatic hernia (CDH) who have adequate gas exchange but elevated pulmonary hypertension and heightened vascular reactivity. Congenital diaphragmatic hernia remains the most common indica- tion for neonatal extracorporeal life support [2]. Though much of the focus has remained on limiting the initiation of ECLS, there is a paucity of literature on how to recognize readiness to wean and facilitate rapid weaning. At our center, our decannulation strategy is to “cut- away” the ECLS circuit while leaving the cannula in place for potential re-introduction of ECLS should a child fail to thrive. This could facilitate earlier willingness to remove ECLS without introducing the risk of requiring additional recannulations. To date, there is inadequate and conflicting evidence regarding cutting-away practices [3,4]. This retrospective review sought to evaluate our center's practice of “cutting-away” the VA ECLS circuit in neonates with CDH while leaving the cannula in situ for ~24 h for a period of observation during which ECLS can be emergently re-initiated without recannulation. In addition to identifying any risks of the procedure, we endeavored to quantify the benefit to patients. We hypothesized that “cutting-away” was safe with- out major morbidity and may help prevent the need for recannulation. 1. Methods 1.1. Setting This was an Institutional Review Board approved (HUM 00153572), retrospective cohort study conducted at CS Mott Children's Hospital at the University of Michigan from January 2014 to September 2018 during which “cutting-away” from ECLS was routine practice. The ECLS care team consists of pediatric surgeons, surgical, pediatric cardiac Journal of Pediatric Surgery 55 (2020) 29–32 ☆ How this paper will improve care: A retrospective review of delayed decannulation in patients with diaphragmatic hernia shows leaving the cannulas in place overnight is safe and helps identify early failures when trialing off ECMO. ⁎ Corresponding author at: Department of Surgery, University of Michigan, 1540 E Hos- pital Drive, Ann Arbor, MI 48109. E-mail address: samirg@med.umich.edu (S.K. Gadepalli). https://doi.org/10.1016/j.jpedsurg.2019.09.070 0022-3468/© 2019 Elsevier Inc. All rights reserved. Contents lists available at ScienceDirect Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg