Yong Loo Lin School of Medicine, National University of Singapore.
Saw Swee School of Public Health, National University of Singapore.
Cardiovasc Pathol. 2019 Jul-Aug;41:24-28. doi: 10.1016/j.carpath.2019.03.001. Epub 2019 Mar 19.
Extracorporeal life support is used as a salvage procedure to treat refractory cardiopulmonary failure. There are limited data addressing discrepancies between pre- and postmortem findings in patients undergoing extracorporeal membrane oxygenation (ECMO). We investigated discrepancies between clinical and autopsy findings in patients placed on ECMO to assess in what proportion of patients were there significant cardiovascular or other pathologies present that were not clinically apparent prior to death.
After institutional review board approval, a list of deceased ECMO patients who underwent autopsy examination from 2004 through 2015 was obtained from our institutional database. Retrospective analyses of findings on clinical investigations done while patients were on ECMO and findings on autopsy examination were compared and stratified according to modified Goldman Criteria, which classify discrepancies into four grades depending on their impact on patient's management and mortality.
Of 19 patients, 18 patients had venoarterial ECMO (9 central + 5 peripheral + 4 conversions of ECMO type) and 1 patient received venovenous ECMO. Clinically unrecognized findings were found on autopsy in all patients. 56.6% of total discrepancies found were major [class I/II; e.g., myocardial infarction (MI), intracranial bleeding]. All patients had major discrepancies (class I/II) with an average of 4.21 class I discrepancies per patient. Class I discrepancies are findings which could have altered the course of treatment and survival of the patient if recognized premortem. The most common discrepancies were cardiovascular (MI 63.2%, marked cardiac remodeling 42.1%, severe coronary disease 31.6%) in nature across four classes of discrepancies.
We found major discrepancies between premortem and postmortem diagnoses in patients who underwent ECMO. Our findings underscore difficulties in clinically diagnosing events on ECMO as well as the need for enhanced surveillance and better diagnostic techniques in ECMO patients. Further prospective studies are necessary to understand effects of ECMO on major organs.
体外生命支持被用作治疗难治性心肺衰竭的抢救程序。在接受体外膜氧合（ECMO）的患者中，关于生前和死后发现之间差异的数据有限。我们研究了接受 ECMO 治疗的患者的临床和尸检结果之间的差异，以评估在多大比例的患者中存在临床上不明显但在死亡前存在的重要心血管或其他病理学。
在获得机构审查委员会批准后，从我们的机构数据库中获得了 2004 年至 2015 年期间接受尸检检查的已故 ECMO 患者的名单。对患者接受 ECMO 治疗时进行的临床研究结果和尸检检查结果进行回顾性分析，并根据改良 Goldman 标准进行分层，该标准根据对患者管理和死亡率的影响将差异分为四级。
19 名患者中，18 名患者接受了静脉动脉 ECMO（9 例中心+5 例外周+4 例 ECMO 类型转换），1 名患者接受了静脉静脉 ECMO。所有患者在尸检时均发现临床上未被识别的发现。总共发现的差异中有 56.6%为主要差异[I/II 级；例如心肌梗死（MI），颅内出血]。所有患者均有主要差异（I/II 级），平均每位患者有 4.21 个 I 级差异。I 级差异是指如果在生前识别出这些差异，可能会改变患者的治疗过程和生存。最常见的差异是心血管疾病（MI 占 63.2%，明显的心脏重构占 42.1%，严重的冠状动脉疾病占 31.6%），横跨四个差异级别。
我们发现接受 ECMO 治疗的患者生前和死后诊断之间存在主要差异。我们的发现强调了在 ECMO 上临床诊断事件的困难，以及在 ECMO 患者中需要增强监测和更好的诊断技术。需要进一步的前瞻性研究来了解 ECMO 对主要器官的影响。
