Department of Pediatrics, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York; Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York.
Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
J Heart Lung Transplant. 2019 Dec;38(12):1275-1285. doi: 10.1016/j.healun.2019.09.004. Epub 2019 Sep 12.
Application of extracorporeal life support (ECLS) for advanced pulmonary hypertension (PH) is evolving and may be deployed as a bridge to transplantation (BTT) or in one of several non-BTT uses, such as bridge to recovery (BTR) to the chronic PH clinical state in the setting of an acute PH trigger, bridge through non-transplant surgery (BTNTS), or bridge post-transplantation (BPT).
We conducted a retrospective analysis of all adult patients with World Symposium on Pulmonary Hypertension Group 1, 3, 4, or 5 PH who received ECLS at Columbia University Medical Center/New York Presbyterian Hospital between January 1, 2010 and August 18, 2018. We describe patient characteristics, outcomes, and our approach to medical and surgical management of these patients.
There were 98 patients with significant PH in the cohort (54 female; median age, 48 years [interquartile range, 32-58]). Of these, 44 (45%) patients with PH received ECLS as non-BTT with intent to recover back to their baseline functional state, optimize therapy, or support through a definitive surgery, including 19 BTR, 17 BTNTS, and 8 BPT, and 54 (55%) patients received ECLS as BTT. In the overall cohort, 67 (68.4%) patients received venoarterial ECLS and 31 (31.6%) received venovenous (VV) ECLS. Out of 83 patients, 52 (63%) were liberated from invasive mechanical ventilation, and 85.2% of BTT patients with PH ambulated while on ECLS. Management of PH medications was individualized, often requiring titration with use of inhaled pulmonary vasodilators increased after cannulation in non-BTT. Overall 30-day survival was 73.5%, survival to ECLS decannulation was 66.3%, and survival to hospital discharge was 54.1%. All 8 BPT patients (100%) survived to hospital discharge, 64.7% of BTNTS patients survived to hospital discharge, and 32 (59.3%) BTT patients survived to lung transplantation. Early-era use of VV-ECLS for BTT had worse survival to discharge than those initially configured with venoarterial ECLS, impacting the overall survival and leading to limited use of VV-ECLS in the current era for BPT, BTNTS, and select BTR cases.
ECLS instituted by a specialized, multidisciplinary team has a role in the management of advanced PH as BTT or as non-BTT (including BTR, BTNTS, and BPT). Careful selection of ECLS cannulation configurations, patient-specific optimization of PH medical therapies, and avoidance of endotracheal intubation may be effective strategies in managing these complex patients.
体外生命支持（ECLS）在晚期肺动脉高压（PH）中的应用正在不断发展，可能被用作移植桥接（BTT）或在几种非 BTT 用途中使用，例如急性 PH 触发时恢复的桥接（BTR）到慢性 PH 临床状态、非移植手术的桥接（BTNTS），或移植后的桥接（BPT）。
我们对 2010 年 1 月 1 日至 2018 年 8 月 18 日期间在哥伦比亚大学医学中心/纽约长老会医院接受 ECLS 的所有患有世界肺高血压协会第 1、3、4 或 5 组 PH 的成年患者进行了回顾性分析。我们描述了患者的特征、结局，以及我们对这些患者进行的医疗和手术管理方法。
该队列中有 98 名有显著 PH 的患者（54 名女性；中位年龄 48 岁[四分位距 32-58]）。其中，44 名（45%）PH 患者接受了非 BTT 的 ECLS，目的是恢复到他们的基线功能状态，优化治疗或通过确定性手术支持，包括 19 例 BTR、17 例 BTNTS 和 8 例 BPT，54 名（55%）患者接受了 ECLS 作为 BTT。在整个队列中，67 名（68.4%）患者接受了静脉动脉 ECLS，31 名（31.6%）接受了静脉静脉（VV）ECLS。在 83 名患者中，52 名（63%）患者成功脱离了有创机械通气，85.2%的 BTT 患者在接受 ECLS 时能够行走。PH 药物的管理是个体化的，通常需要在非 BTT 中使用吸入性肺血管扩张剂进行滴定。总体 30 天生存率为 73.5%，ECLS 脱管生存率为 66.3%，出院生存率为 54.1%。所有 8 例 BPT 患者（100%）均存活至出院，64.7%的 BTNTS 患者存活至出院，32 例（59.3%）BTT 患者存活至肺移植。早期 VV-ECLS 用于 BTT 的使用率低于最初配置的静脉动脉 ECLS，这影响了整体生存率，并导致目前时代对 BPT、BTNTS 和部分 BTR 病例中 VV-ECLS 的使用受限。
由专门的多学科团队实施的 ECLS 在 BTT 或非 BTT（包括 BTR、BTNTS 和 BPT）的管理中具有一定作用。仔细选择 ECLS 插管配置、患者特异性优化 PH 药物治疗，以及避免气管插管，可能是管理这些复杂患者的有效策略。
