Prasad Amit, Ghodsizad Ali, Brehm Christoph, Kozak Mark, Körner Michael, El Banayosy Aly, Singbartl Kai
Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA.
Division of Cardiothoracic Surgery, University of Miami, Miami, FL, USA.
Artif Organs. 2018 Jun;42(6):664-669. doi: 10.1111/aor.13082. Epub 2018 Jan 18.
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides mechanical circulatory support for patients with advanced cardiogenic shock, facilitating myocardial recovery and limiting multi-organ failure. In patients with severely limited left ventricular ejection, peripheral VA-ECMO can further increase left ventricular and left atrial pressures (LAP). Failure to decompress the left heart under these circumstances can result in pulmonary edema and upper body hypoxemia, that is, myocardial and cerebral ischemia. Atrial septostomy can decrease LAP in these situations. However, the effects of atrial septostomy on upper body oxygenation remain unknown. After IRB approval, we identified 9 out of 242 adult VA-ECMO patients between January 2011 and June 2016 who also underwent atrial septostomy for refractory pulmonary edema/upper body hypoxemia. We analyzed LAP/pulmonary capillary wedge pressure (PCWP), right atrial pressures (RAPs), P O /F O ratios (blood samples from right radial artery), intrathoracic volume status, and resolution of pulmonary edema before and up to 48 h after septostomy. There were no procedure-related complications. Thirty-day survival was 44%. LAP/PCWP decreased by approximately 40% immediately following septostomy and remained so for at least 24 h. P O /F O ratios significantly increased from 0.49 (0.38-2.12) before to 5.35 (3.01-7.69) immediately after septostomy and continued so for 24 h, 6.6 (4.49-10.93). Radiographic measurements also indicated a significant improvement in thoracic intravascular volume status after atrial septostomy. Atrial septostomy reduces LAP and improves upper body oxygenation and intrathoracic vascular volume status in patients developing severe refractory pulmonary edema while undergoing peripheral VA-ECMO. Atrial septostomy therefore appears safe and suitable to reduce the risk of upper body ischemia under these circumstances.
静脉-动脉体外膜肺氧合（VA-ECMO）为晚期心源性休克患者提供机械循环支持，促进心肌恢复并限制多器官功能衰竭。在左心室射血严重受限的患者中，外周VA-ECMO会进一步升高左心室和左心房压力（LAP）。在这种情况下，未能对左心进行减压可导致肺水肿和上身低氧血症，即心肌和脑缺血。房间隔造口术可在这些情况下降低LAP。然而，房间隔造口术对上半身氧合的影响尚不清楚。经机构审查委员会（IRB）批准，我们在2011年1月至2016年6月期间的242例成年VA-ECMO患者中确定了9例，这些患者也因难治性肺水肿/上身低氧血症接受了房间隔造口术。我们分析了造口术前直至造口术后48小时的LAP/肺毛细血管楔压（PCWP）、右心房压力（RAP）、PO/FO比值（来自右桡动脉的血样）、胸腔内容量状态以及肺水肿的消退情况。未出现与手术相关的并发症。30天生存率为44%。造口术后LAP/PCWP立即下降约40%，并至少持续24小时。PO/FO比值从造口术前的0.49（0.38 - 2.12）显著升至造口术后即刻的5.35（3.01 - 7.69），并持续24小时，为6.6（4.49 - 10.93）。影像学测量也表明房间隔造口术后胸腔内血管容量状态有显著改善。在接受外周VA-ECMO时出现严重难治性肺水肿的患者中，房间隔造口术可降低LAP，改善上半身氧合和胸腔内血管容量状态。因此，在这些情况下，房间隔造口术似乎安全且适合降低上身缺血风险。
