Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany.
Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany.
J Thorac Cardiovasc Surg. 2018 Feb;155(2):643-649. doi: 10.1016/j.jtcvs.2017.09.045. Epub 2017 Sep 20.
Pulmonary endarterectomy (PEA) is the only curative treatment option for patients with chronic thromboembolic pulmonary hypertension. Massive endobronchial bleeding that precludes weaning from cardiopulmonary bypass is an often-fatal complication of PEA. The aim of this study was to determine whether short-term extracorporeal membrane oxygenation (ECMO) is a safe and feasible procedure in patients with severe endobronchial bleeding.
From January 2014 to December 2016, 396 patients (mean age 60 ± 18 years, 54.5% male) underwent PEA in our department. Patients with severe endobronchial hemorrhage at the time of weaning from cardiopulmonary bypass (CPB) were switched to a heparin-coated venoarterial ECMO circuit. After full-dose protamine administration to restore normal coagulation, weaning from ECMO was attempted in the operating room.
In-hospital mortality was 2.3% (9/396 patients). Eight patients (2.0%) developed severe endobronchial bleeding classified as diffuse (n = 6) or localized (n = 2) by bronchoscopy. After reinstitution of CPB and subsequent switch to ECMO, the mean duration of ECMO support was 49 ± 13 minutes, and all 8 patients were weaned successfully from ECMO in the operating theater without further signs of endobronchial bleeding. One patient needed venovenous ECMO support for poor oxygenation 6 hours after surgery. Seven patients were discharged after a prolonged postoperative stay of 17.6 ± 4.1 days. One patient died. This new concept significantly reduced mortality compared with previous (2009-2013) ECMO support (P = .0406).
For patients with massive endobronchial bleeding after PEA, the intraoperative switch from CPB to venoarterial ECMO support with full-dose protamine administration is a new and potentially life-saving treatment concept.
肺动脉内膜剥脱术（PEA）是治疗慢性血栓栓塞性肺动脉高压患者的唯一根治性治疗方法。PEA 术后因大量支气管内出血而无法脱离体外循环是一种常导致死亡的并发症。本研究旨在确定在严重支气管内出血的患者中，短期体外膜肺氧合（ECMO）是否是一种安全可行的方法。
2014 年 1 月至 2016 年 12 月，我院共 396 例患者（平均年龄 60±18 岁，54.5%为男性）接受了 PEA 治疗。在脱离体外循环（CPB）时出现严重支气管内出血的患者被切换到肝素涂层的动静脉 ECMO 回路。在给予全剂量鱼精蛋白以恢复正常凝血后，在手术室尝试 ECMO 脱机。
住院死亡率为 2.3%（9/396 例患者）。8 例（2.0%）患者发生严重支气管内出血，支气管镜下表现为弥漫性（n=6）或局限性（n=2）。重新建立 CPB 并随后切换到 ECMO 后，ECMO 支持的平均时间为 49±13 分钟，所有 8 例患者均在手术室成功地从 ECMO 脱机，且无进一步的支气管内出血迹象。1 例患者术后 6 小时因氧合不良需要静脉-静脉 ECMO 支持。7 例患者在术后延长的住院时间 17.6±4.1 天后出院。1 例患者死亡。与之前（2009-2013 年）的 ECMO 支持相比，这一新概念显著降低了死亡率（P=0.0406）。
对于 PEA 术后发生大量支气管内出血的患者，术中从 CPB 切换至静脉-动脉 ECMO 支持并给予全剂量鱼精蛋白是一种新的、有潜在救生作用的治疗概念。
