Ishisaka Yoshiko, Watanabe Atsuyuki, Takagi Hisato, Takayama Hiroo, Wiley Jose, Kuno Toshiki
Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth, Israel.
Division of Hospital Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan.
J Intensive Care Med. 2023 Sep;38(9):785-796. doi: 10.1177/08850666231178262. Epub 2023 May 24.
Pulmonary endarterectomy (PEA) is known to be a curative intervention for chronic thromboembolic pulmonary hypertension (CTEPH). Its complications include endobronchial bleeding, persistent pulmonary arterial hypertension, right ventricular failure, and reperfusion lung injury. Extracorporeal membranous oxygenation (ECMO) is a perioperative salvage method for PEA. Although risk factors and outcomes have been reported in several studies, overall trends remain unknown. We performed a systematic review and study-level meta-analysis to understand the outcomes of ECMO utilization in the perioperative period of PEA. We performed a literature search with PubMed and EMBASE on 11/18/2022. We included studies including patients who underwent perioperative ECMO in PEA. We collected data including baseline demographics, hemodynamic measurements, and outcomes such as mortality and weaning of ECMO and performed a study-level meta-analysis. Eleven studies with 2632 patients were included in our review. ECMO insertion rate was 8.7% (225/2,625, 95% CI 5.9-12.5) in total, VV-ECMO was performed as the initial intervention in 1.1% (41/2,625, 95% CI 0.4-1.7) (Figure 3), and VA-ECMO was performed as an initial intervention in 7.1% (184/2,625, 95% CI 4.7-9.9). Preoperative hemodynamic measurements showed higher pulmonary vascular resistance, mean pulmonary arterial pressure, and lower cardiac output in the ECMO group. Mortality rates were 2.8% (32/1238, 95% CI: 1.7-4.5) in the non-ECMO group and 43.5% (115/225, 95% CI: 30.8-56.2) in the ECMO group. The proportion of patients with successful weaning of ECMO was 72.6% (111/188, 95% CI: 53.4-91.7). Regarding complications of ECMO, the incidence of bleeding and multi-organ failure were 12.2% (16/79, 95% CI: 13.0-34.8) and 16.5% (15/99, 95% CI: 9.1-28.1), respectively. Our systematic review showed a higher baseline cardiopulmonary risk in patients with perioperative ECMO in PEA, and its insertion rate was 8.7%. Further studies that compare the use of ECMO in high-risk patients who undergo PEA are anticipated.
肺血栓内膜剥脱术（PEA）是治疗慢性血栓栓塞性肺动脉高压（CTEPH）的一种根治性干预措施。其并发症包括支气管内出血、持续性肺动脉高压、右心衰竭和再灌注肺损伤。体外膜肺氧合（ECMO）是PEA围手术期的一种挽救方法。尽管多项研究报道了相关危险因素和结果，但总体趋势仍不明确。我们进行了一项系统评价和研究水平的荟萃分析，以了解PEA围手术期使用ECMO的结果。2022年11月18日，我们使用PubMed和EMBASE进行了文献检索。我们纳入了包括接受PEA围手术期ECMO治疗患者的研究。我们收集了包括基线人口统计学、血流动力学测量以及死亡率和ECMO撤机等结果的数据，并进行了研究水平的荟萃分析。我们的综述纳入了11项研究，共2632例患者。ECMO总体置入率为8.7%（225/2625，95%CI 5.9-12.5），1.1%（41/2625，95%CI 0.4-1.7）的患者最初采用静脉-静脉ECMO（VV-ECMO）治疗（图3），7.1%（184/2625，95%CI 4.7-9.9）的患者最初采用静脉-动脉ECMO（VA-ECMO）治疗。术前血流动力学测量显示，ECMO组的肺血管阻力、平均肺动脉压较高，心输出量较低。非ECMO组的死亡率为2.8%（32/1238，9%CI：1.7-4.5），ECMO组为43.5%（115/225，95%CI：30.8-56.2）。ECMO成功撤机患者的比例为72.6%（111/188，95%CI：53.4-91.7）。关于ECMO的并发症，出血和多器官功能衰竭的发生率分别为12.2%（16/79，95%CI：13.0-34.8）和16.5%（15/99，95%CI：9.1-28.1）。我们的系统评价显示，PEA围手术期接受ECMO治疗的患者基线心肺风险较高，其置入率为8.7%。预计将开展进一步研究，比较PEA高危患者使用ECMO的情况。
