Pollert Lukas, Prikrylova Zuzana, Berousek Jan, Mosna Frantisek, Lischke Robert
Department of Anaesthesiology and Intensive Care, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic.
3rd Surgical Department, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, Praha, Czech Republic.
Ther Clin Risk Manag. 2016 Jun 16;12:1003-8. doi: 10.2147/TCRM.S109033. eCollection 2016.
Lung transplantation is considered an established treatment for patients with end-stage chronic respiratory failure. Patients with acute respiratory failure requiring respiratory support with invasive mechanical ventilation while awaiting lung transplantation are at high risk of death. Extracorporeal membrane oxygenation (ECMO) has been proposed as an alternative bridging strategy to mechanical ventilation. The shear stress created by the mechanical pumps causes changes in the hematological system in almost all patients treated with ECMO. An antithrombotic strategy to mitigate ECMO bleeding and thrombotic complications is necessary. The use of thrombolytic therapy is recommended for patients with acute symptomatic embolism with associated hypotension or shock. In this setting, the hemodynamic benefits of thrombolytic treatment far outweigh its bleeding risk.
This case report describes a 32-year-old woman suffering from lymphangioleiomyomatosis, who underwent urgent double-lung transplantation. This patient was maintained on ECMO preoperatively, perioperatively, and postoperatively due to life-threatening hypoxemia caused by the progression of her pulmonary tissue damage. Multiple thrombi developed in the early postoperative period, in both right and left heart atria. Direct thrombolysis was successfully performed on the first postoperative day.
According to the current published literature, direct thrombolysis of thrombi in both right and left atria in a patient supported on ECMO following urgent double-lung transplantation is an extremely rare treatment method. Even when taking into account all of the risks associated with thrombolysis and arteriovenous ECMO support, we found that this technique is very effective and, without a doubt, it saved the life of our patient.
肺移植被认为是终末期慢性呼吸衰竭患者的既定治疗方法。在等待肺移植期间需要有创机械通气进行呼吸支持的急性呼吸衰竭患者死亡风险很高。体外膜肺氧合（ECMO）已被提议作为机械通气的替代桥接策略。机械泵产生的剪切应力几乎会使所有接受ECMO治疗的患者的血液系统发生变化。采取抗血栓策略以减轻ECMO出血和血栓形成并发症是必要的。对于伴有低血压或休克的急性症状性栓塞患者，建议使用溶栓治疗。在这种情况下，溶栓治疗的血流动力学益处远大于其出血风险。
本病例报告描述了一名患有淋巴管平滑肌瘤病的32岁女性，她接受了紧急双肺移植。由于肺部组织损伤进展导致危及生命的低氧血症，该患者在术前、术中和术后均接受ECMO支持。术后早期，左右心房均出现多个血栓。术后第一天成功进行了直接溶栓。
根据目前已发表的文献，在紧急双肺移植后接受ECMO支持的患者中，对左右心房血栓进行直接溶栓是一种极其罕见的治疗方法。即使考虑到与溶栓和动静脉ECMO支持相关的所有风险，我们发现这种技术非常有效，而且毫无疑问，它挽救了我们患者的生命。
