肺栓塞致院外心脏骤停患者行血管内体外膜肺氧合治疗的神经转归和再灌注策略：一项多中心回顾性队列研究的事后分析。

Neurological outcomes and reperfusion strategies in out-of-hospital cardiac arrest patients due to pulmonary embolism who underwent venoarterial extracorporeal membrane oxygenation: A post-hoc analysis of a multicenter retrospective cohort study.

机构信息

JA Hiroshima General Hospital, Department of Emergency and Intensive Care Medicine, Jigozen 1-3-3, Hatsukaichi, Hiroshima 738-8503, Japan; Shiga University, Graduate School of Data Science, 1-1-1 Banba, Hikone, Shiga 522-8522, Japan.

St. Luke's International Hospital, Department of Emergency and Critical Care Medicine, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan.

出版信息

Resuscitation. 2023 Oct;191:109926. doi: 10.1016/j.resuscitation.2023.109926. Epub 2023 Aug 5.

DOI:10.1016/j.resuscitation.2023.109926

PMID:37544497

Abstract

INTRODUCTION

This study aimed to evaluate the effect of different reperfusion strategies on neurological outcomes in patients with pulmonary embolism who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for out-of-hospital cardiac arrest (OHCA).

METHODS

This was a post-hoc analysis of a multicenter retrospective cohort study conducted in 36 institutions in Japan over six years. We included patients who underwent VA-ECMO and were diagnosed with pulmonary embolism caused by OHCA. Neurological outcomes were evaluated on the basis of the cerebral performance category at hospital discharge. We also assessed the association between reperfusion strategies and successful separation from ECMO.

RESULTS

Among the 78 included patients, approximately half were successfully weaned from ECMO. Hospital mortality and favorable neurological outcomes at hospital discharge were 60.3% and 17.9%, respectively. Thirty-one patients (39.7%) underwent reperfusion strategies after ECMO, including 13 who received systemic thrombolytic therapy and 18 who underwent mechanical reperfusion strategy. After adjusting for prespecified covariates using the competing risk model, reperfusion strategies increased ECMO separation rate (systemic thrombolytic therapy: subdistribution hazard ratio [sHR] 2.24, 95% confidence interval [CI] 1.21-4.17, P = 0.011; mechanical reperfusion strategy: sHR 1.70, 95% CI 0.86-3.41, P = 0.129) compared with anticoagulation therapy alone, whereas higher cardiac Sequential Organ Failure Assessment score decreased ECMO separation rate (sHR 0.81, 95% CI 0.67-0.97, P = 0.020).

CONCLUSIONS

Favorable neurological outcomes were observed in less than 20% of patients with OHCA due to pulmonary embolism undergoing ECMO. Reperfusion strategies may be associated with shorter ECMO durations in these patients.

CLINICAL TRIAL REGISTRATION

https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

摘要

介绍

本研究旨在评估不同再灌注策略对因院外心脏骤停（OHCA）接受静脉-动脉体外膜肺氧合（VA-ECMO）治疗的肺栓塞患者神经功能结局的影响。

方法

这是一项在日本 36 家机构进行的为期六年的多中心回顾性队列研究的事后分析。我们纳入了接受 VA-ECMO 治疗并被诊断为 OHCA 引起的肺栓塞的患者。根据出院时的脑功能分类评估神经功能结局。我们还评估了再灌注策略与 ECMO 成功分离之间的关联。

结果

在 78 例纳入患者中，约一半成功脱离 ECMO。住院死亡率和出院时的良好神经功能结局分别为 60.3%和 17.9%。31 例（39.7%）患者在 ECMO 后接受了再灌注策略，其中 13 例接受了全身溶栓治疗，18 例接受了机械再灌注策略。在校正了竞争风险模型中的预设协变量后，与单独抗凝治疗相比，再灌注策略增加了 ECMO 分离率（全身溶栓治疗：亚分布危险比[ sHR]2.24，95%置信区间[CI]1.21-4.17，P=0.011；机械再灌注策略：sHR 1.70，95%CI 0.86-3.41，P=0.129），而较高的心脏序贯器官衰竭评估评分降低了 ECMO 分离率（sHR 0.81，95%CI 0.67-0.97，P=0.020）。