Feng Iris, Singh Sameer, Kobsa Serge S, Zhao Yanling, Kurlansky Paul A, Zhang Ashley, Vaynrub Anna J, Fried Justin A, Takeda Koji
Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, New York, USA.
Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA.
Interdiscip Cardiovasc Thorac Surg. 2024 Aug 1;39(2). doi: 10.1093/icvts/ivae148.
This study sought to demonstrate outcomes of veno-arterial extracorporeal life support (VA-ECLS) in non-intubated ('awake') patients with cardiogenic shock, as very few studies have investigated safety and feasibility in this population.
This was a retrospective review of 394 consecutive VA-ECLS patients at our institution from 2017 to 2021. We excluded patients cannulated for indications definitively associated with intubation. Patients were stratified by intubation status at time of cannulation and baseline differences were balanced by inverse probability of treatment weighting. The primary outcome was in-hospital mortality while secondary outcomes included adverse events during ECLS and destination at discharge.
Out of 135 patients in the final cohort, 79 were intubated and 56 were awake at time of cannulation. All awake patients underwent percutaneous femoral cannulation with technical success of 100% without intubation. Indications for VA-ECLS in awake patients included acute decompensated heart failure (64.3%), pulmonary hypertension or massive pulmonary embolism (12.5%), myocarditis (8.9%) and acute myocardial infarction (5.4%). After adjustment, awake and intubated patients had similar ECLS duration (7 vs 6 days, P = 0.19), in-hospital mortality (39.6% vs 51.7%, P = 0.28), and rates of various adverse events. Intubation status was not a significant risk factor for 90-day mortality (hazard ratio [95% confidence interval]: 1.26 [0.64, 2.45], P = 0.51) in multivariable analysis. Heart transplantation (15.1% vs 4.9%) and ventricular assist device (17.4% vs 2.2%) were more common destinations at discharge in awake patients than intubated patients (P = 0.02).
Awake VA-ECLS is safe and feasible with comparable outcomes as intubated counterparts in select cardiogenic shock patients.
本研究旨在证明静脉-动脉体外膜肺氧合（VA-ECLS）在非插管（“清醒”）的心源性休克患者中的治疗效果，因为很少有研究调查过该人群使用VA-ECLS的安全性和可行性。
这是一项对2017年至2021年在我们机构接受VA-ECLS治疗的394例连续患者的回顾性研究。我们排除了因明确与插管相关的适应症而进行插管的患者。根据插管时的插管状态对患者进行分层，并通过治疗权重的逆概率平衡基线差异。主要结局是住院死亡率，次要结局包括ECLS期间的不良事件和出院目的地。
在最终队列的135例患者中，79例在插管时已插管，56例在插管时清醒。所有清醒患者均接受经皮股动脉插管，技术成功率为100%，无需插管。清醒患者接受VA-ECLS的适应症包括急性失代偿性心力衰竭（64.3%）、肺动脉高压或大面积肺栓塞（12.5%）、心肌炎（8.9%）和急性心肌梗死（5.4%）。调整后，清醒和插管患者的ECLS持续时间相似（7天对6天，P = 0.19），住院死亡率相似（39.6%对51.7%，P = 0.28），各种不良事件发生率也相似。在多变量分析中，插管状态不是90天死亡率的显著危险因素（风险比[95%置信区间]：1.26[0.64，2.45]，P = 0.51）。与插管患者相比，清醒患者出院时更常见的目的地是心脏移植（15.1%对4.9%）和心室辅助装置（17.4%对2.2%）（P = 0.02）。
在某些心源性休克患者中，清醒状态下的VA-ECLS是安全可行的，其结局与插管患者相当。
