Hoechter Dominik J, Shen Yu-Ming, Kammerer Tobias, Günther Sabina, Weig Thomas, Schramm René, Hagl Christian, Born Frank, Meiser Bruno, Preissler Gerhard, Winter Hauke, Czerner Stephan, Zwissler Bernhard, Mansmann Ulrich U, von Dossow Vera
From the *Department of Anesthesiology, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany; †Institute of Medical Biometry and Epidemiology, Ludwig-Maximilians-University (LMU), Munich, Germany; ‡Clinic of Cardiac Surgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany; §Transplantation Center, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany; and ¶Department of General, Visceral, Transplant, Vascular and Thoracic Surgery, University Hospital, Ludwig-Maximilians-University (LMU), Munich, Germany.
ASAIO J. 2017 Sep/Oct;63(5):551-561. doi: 10.1097/MAT.0000000000000549.
Extracorporeal circulation (ECC) is an invaluable tool in lung transplantation (lutx). More than the past years, an increasing number of centers changed their standard for intraoperative ECC from cardiopulmonary bypass (CPB) to extracorporeal membrane oxygenation (ECMO) - with differing results. This meta-analysis reviews the existing evidence. An online literature research on Medline, Embase, and PubMed has been performed. Two persons independently judged the papers using the ACROBAT-NRSI tool of the Cochrane collaboration. Meta-analyses and meta-regressions were used to determine whether veno-arterial ECMO (VA-ECMO) resulted in better outcomes compared with CPB. Six papers - all observational studies without randomization - were included in the analysis. All were considered to have serious bias caused by heparinization as co-intervention. Forest plots showed a beneficial trend of ECMO regarding blood transfusions (packed red blood cells (RBCs) with an average mean difference of -0.46 units [95% CI = -3.72, 2.80], fresh-frozen plasma with an average mean difference of -0.65 units [95% CI = -1.56, 0.25], platelets with an average mean difference of -1.72 units [95% CI = -3.67, 0.23]). Duration of ventilator support with an average mean difference of -2.86 days [95% CI = -11.43, 5.71] and intensive care unit (ICU) length of stay with an average mean difference of -4.79 days [95% CI = -8.17, -1.41] were shorter in ECMO patients. Extracorporeal membrane oxygenation treatment tended to be superior regarding 3 month mortality (odds ratio = 0.46, 95% CI = 0.21-1.02) and 1 year mortality (odds ratio = 0.65, 95% CI = 0.37-1.13). However, only the ICU length of stay reached statistical significance. Meta-regression analyses showed that heterogeneity across studies (sex, year of ECMO implementation, and underlying disease) influenced differences. These data indicate a benefit of the intraoperative use of ECMO as compared with CPB during lung transplant procedures regarding short-term outcome (ICU stay). There was no statistically significant effect regarding blood transfusion needs or long-term outcome. The superiority of ECMO in lutx patients remains to be determined in larger multi-center randomized trials.
体外循环（ECC）是肺移植（LUTX）中一项非常重要的工具。在过去几年里，越来越多的中心将术中ECC的标准从体外循环（CPB）改为体外膜肺氧合（ECMO），但结果各异。本荟萃分析回顾了现有证据。我们在Medline、Embase和PubMed上进行了在线文献检索。两人使用Cochrane协作组织的ACROBAT-NRSI工具独立对论文进行评估。采用荟萃分析和荟萃回归来确定静脉-动脉体外膜肺氧合（VA-ECMO）与CPB相比是否能带来更好的结果。分析纳入了6篇论文，均为非随机观察性研究。所有研究都被认为因肝素化作为共同干预而存在严重偏倚。森林图显示，在输血方面（浓缩红细胞（RBC）平均差值为-0.46单位[95%CI=-3.72，2.80]，新鲜冰冻血浆平均差值为-0.65单位[95%CI=-1.56，0.25]，血小板平均差值为-1.72单位[95%CI=-3.67，0.23]），ECMO有有益趋势。ECMO患者的呼吸机支持时间平均差值为-2.86天[95%CI=-11.43，5.71]，重症监护病房（ICU）住院时间平均差值为-4.79天[95%CI=-8.17，-1.41]，均较短。体外膜肺氧合治疗在3个月死亡率（比值比=0.46，95%CI=0.21-1.02）和1年死亡率（比值比=0.65，95%CI=0.37-1.13）方面倾向于更优。然而，只有ICU住院时间达到统计学显著性。荟萃回归分析表明，研究间的异质性（性别、ECMO实施年份和基础疾病）影响了差异。这些数据表明，在肺移植手术中，与CPB相比，术中使用ECMO在短期结局（ICU住院时间）方面有优势。在输血需求或长期结局方面没有统计学显著影响。ECMO在LUTX患者中的优越性仍有待在更大规模的多中心随机试验中确定。
