Razavi Journal of Medicine

Razavi Journal of Medicine

Low Cardiac Output Syndrome After Pediatric Congenital Heart Surgery: A Contemporary Scoping Review From Mechanisms to Emergency Mechanical Support Intervention

Articles in Press

Document Type : Review Article/ Systematic Review Article/ Meta Analysis

Authors
Atefeh Shirinzadeh Feizabadi 1
Mohsen Ebrahimi 2
Hossein Akhavan 3
Hamideh Yaghoobi 4
Mozhdeh Taheri Afshar 5
Hamid Zamani Moghadam 2
Mohsen Yaghubi 6
1 Department of Anesthesiology, School of Paramedical Sciences, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
2 Department of Emergency Medicine, School of Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
3 Department of Pediatrics, School of Medicine, Sheikh Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.
4 Department of Nursing, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
5 Student Research Committee, Ramsar Fatemeh Zahra School of Nursing and Midwifery, Health Research Institue, Babol University of Medical Sciences, Babol, Iran.
6 M.Sc in Extra-Corporal Technology, Department of Extra-Corporeal Circulation (ECC), Razavi Hospital, Mashhad, Iran.
10.30483/rjm.2026.254790.1538
Abstract
Context: Low cardiac output syndrome (LCOS) affects up to 25% of children after congenital heart surgery and remains a major cause of morbidity. While temporary mechanical circulatory support (tMCS) options have expanded, with ECMO remaining the cornerstone and Impella emerging as an adjunct in selected older children, comprehensive evidence synthesis integrating pathophysiology with contemporary multicenter outcomes is lacking. This scoping review maps current evidence on the pathophysiology, early recognition, and evolving tMCS strategies for pediatric post-cardiotomy LCOS, with emphasis on developmentally appropriate approaches.

Evidence Acquisition: Following Arksey and O'Malley's framework and JBI methodology, we systematically searched PubMed/MEDLINE, Scopus, and Web of Science (January 2015 to October 2025). Inclusion criteria: original research, systematic reviews, meta-analyses, and consensus statements on pediatric (0–18 years) post-cardiotomy LCOS managed with pharmacological support or tMCS. Data were narratively synthesized with a focus on multicenter collaborative evidence.

Results: From 847 initially identified records, 42 studies met the inclusion criteria. Pediatric LCOS pathophysiology differs fundamentally from that of adults due to myocardial immaturity, single-ventricle physiology, and lesion-specific hemodynamics. The 2025 meta-analysis (N=1,200) demonstrated that levosimendan reduces the incidence of LCOS compared with milrinone (RR 0.67, p=0.001). The ACTION collaborative (N=150, 29 centers) reported 89.3% positive outcomes with Impella (preliminary registry data, presented at the 2025 ACTION annual meeting) (32.7% recovery, 32% bridge-to-transplant, 23.3% bridge-to-durable VAD). However, complications were 2.3-fold higher in patients <35 kg. ECPELLA achieved 45–62.5% recovery in adolescents.

Conclusions: Contemporary pediatric LCOS management requires developmentally tailored approaches integrating vigilant monitoring, targeted pharmacotherapy, and timely tMCS. Emerging collaborative network data are transforming care toward evidence-based practice. However, significant knowledge gaps remain in device-selection algorithms and the optimal timing of support initiation.
Keywords
Pediatric cardiac surgery
congenital heart disease
low cardiac output syndrome
mechanical circulatory support
extracorporeal membrane oxygenation

Acknowledgements: The authors would like to express their gratitude to the ACTION Network and ELSO registry contributors for making their data publicly available.


Availability of data and materials: The data that support the findings of this study are available from the corresponding author upon reasonable request.


Conflicts of interest: The authors have no conflicts of interest to declare.


Consent for publication: Not applicable.


Ethics approval and consent to participate: This study received ethical approval from the Research Ethics Committee of Mashhad University of Medical Sciences, Iran (Code: IR.MUMS.REC.1399.082).


Financial disclosure: No financial support was received for this study.


Author contributions: M.H.M. M.E. and H.Z.M. Contributed to the conception of the work, revising the draft, approving the final version of the manuscript, and agreeing on all aspects of the work; H.Y. and M.T.A. Contributed to the conception and design of the study, drafting of the manuscript and critical revision, and approval of final version, H.A. and M.Y. Contributed to the conception and design of the study, drafting of the manuscript and critical revision, and approval of final version.

Open Access Policy: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/

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Razavi Journal of Medicine

Articles in Press, Accepted Manuscript
Available Online from 01 September 2026