Fiser William P, Yetman Anji T, Gunselman Ryan J, Fasules James W, Baker Lorrie L, Chipman Carl W, Morrow William R, Frazier Elizabeth A, Drummond-Webb Jonathan J
Pediatric and Congenital Cardiac Surgery, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72202, USA.
J Heart Lung Transplant. 2003 Jul;22(7):770-7. doi: 10.1016/s1053-2498(02)00808-2.
Since 1990, extracorporeal membrane oxygenation (ECMO) has been used as a bridge to cardiac transplantation in 47 patients.
A review of the ECMO database, approved by the Arkansas Children's Hospital institutional review board, forms the basis of this report. We made statistical comparison using Fisher's exact probability testing. The ECMO circuitry was a roller occlusion pump with computer-assisted perfusion system technology.
Thirty-two (68%) patients underwent transcatheter septostomy for cardiac decompression. Diagnosis at presentation was either congenital heart disease (CHD, n = 15) or cardiomyopathy (n = 32). Ages ranged from 1 day to 22 years old (median, 18 months old), and weight ranged from 2.9 to 100 kg (median, 10 kg). The average duration of support was 242 hours (range, 22-1078 hours). Overall long-term survival was 47%, with 16 (34%) patients successfully bridged to cardiac transplantation (of which 9 [56%] survived) and 13 (28%) successfully weaned from ECMO. Patients undergoing ECMO after cardiotomy had 31% survival. Survival was improved significantly (p < 0.02) in patients with cardiomyopathy (59%) vs those with CHD (20%). Patients with cardiomyopathy underwent 8 transplantations with 7 survivors (88%), whereas in the CHD group, there were 8 transplantations with only 2 survivors (25%), p < 0.05. Sub-analysis of the cardiomyopathy group revealed that patients with acute cardiomyopathy in association with documented viral illness had a 75% chance of being weaned from ECMO without undergoing transplantation. Complications during ECMO occurred in 45% of survivors and were more frequent in non-survivors. Infectious complications were most frequent, followed by neurologic complications, technical ECMO problems, and renal insufficiency.
Patients with cardiomyopathy has a better prognosis than did those with CHD when using ECMO as a bridge to transplantation or survival. Complications are significant and increase with the duration of support. Extracorporeal membrane oxygenation for salvage and subsequent transplantation in this high-risk group of patients requires critical review. Alternative support options must be developed in the pediatric population that will allow improved outcomes, comparable with outcomes achieved in the adult population.
自1990年以来，体外膜肺氧合（ECMO）已被用于47例患者作为心脏移植的桥梁。
本报告基于对经阿肯色儿童医院机构审查委员会批准的ECMO数据库的回顾。我们使用Fisher精确概率检验进行统计比较。ECMO回路是带有计算机辅助灌注系统技术的滚压式阻塞泵。
32例（68%）患者接受了经导管房间隔造口术以进行心脏减压。就诊时的诊断为先天性心脏病（CHD，n = 15）或心肌病（n = 32）。年龄范围为1天至22岁（中位数为18个月），体重范围为2.9至100千克（中位数为10千克）。平均支持时间为242小时（范围为22 - 1078小时）。总体长期生存率为47%，16例（34%）患者成功过渡到心脏移植（其中9例[56%]存活），13例（28%）成功脱离ECMO。心脏切开术后接受ECMO的患者生存率为31%。心肌病患者的生存率（59%）显著高于CHD患者（20%）（p < 0.02）。心肌病患者进行了8例移植，7例存活（88%），而在CHD组中，8例移植仅有2例存活（25%），p < 0.05。对心肌病组的亚分析显示，伴有记录在案的病毒感染的急性心肌病患者有75%的机会在不进行移植的情况下脱离ECMO。45%的存活者在ECMO期间出现并发症，非存活者中更常见。感染性并发症最常见，其次是神经系统并发症、ECMO技术问题和肾功能不全。
当使用ECMO作为移植或生存的桥梁时，心肌病患者的预后比CHD患者更好。并发症很严重，且随着支持时间的延长而增加。对于这一高危患者群体，采用体外膜肺氧合进行挽救及后续移植需要严格审查。必须在儿科人群中开发替代支持方案，以实现与成人人群相当的改善结局。
