难治性心源性休克患者外周至中心体外膜肺氧合转换：结局与过渡策略
Peripheral-to-central extracorporeal corporeal membrane oxygenation switch in refractory cardiogenic shock patients: outcomes and bridging strategies.
作者信息
Besnard Aurélie, Moyon Quentin, Lebreton Guillaume, Demondion Pierre, Hékimian Guillaume, Chommeloux Juliette, Petit Matthieu, Gautier Melchior, Lefevre Lucie, Saura Ouriel, Levy David, Schmidt Matthieu, Leprince Pascal, Luyt Charles-Edouard, Combes Alain, Pineton de Chambrun Marc
机构信息
Service de Médecine Intensive-Réanimation, Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, 47-83, Boulevard de l'Hôpital, Paris Cedex, 75651, France.
Syndrome des Anticorps Anti-phospholipides et Autres Maladies Auto-Immunes Systémiques Rares, Sorbonne Université, AP-HP, Hôpital La Pitié-Salpêtrière, Centre de Référence National Lupus Systémique, Institut E3M, Service de Médecine Interne 2, Paris, France.
出版信息
Ann Intensive Care. 2024 Oct 7;14(1):154. doi: 10.1186/s13613-024-01382-3.
BACKGROUND
Peripheral veno-arterial extracorporeal membrane oxygenation (pECMO) has become the first-line device in refractory cardiogenic shock (rCS). Some pECMO complications can preclude any bridging strategies and a peripheral-to-central ECMO (cECMO) switch can be considered as a bridge-to-decision. We conducted this study to appraise the in-hospital survival and the bridging strategies in patients undergoing peripheral-to-central ECMO switch.
METHODS
This retrospective monocenter study included patients admitted to a ECMO-dedicated intensive care unit from February 2006 to January 2023. Patients with rCS requiring pECMO switched to cECMO were included. Patients were not included when the cECMO was the first mechanical circulatory support.
RESULTS
Eighty patients, with a median [IQR25-75] age of 44 [29-53] years at admission and a female-to-male sex ratio of 0.6 were included in the study. Refractory pulmonary edema was the main switching reason. Thirty patients (38%) were successfully bridged to: heart transplantation (n = 16/80, 20%), recovery (n = 10/80, 12%) and ventricle assist device (VAD, n = 4/30, 5%) while the others died on cECMO (n = 50/80, 62%). The most frequent complications were the need for renal replacement therapy (76%), hemothorax or tamponade (48%), need for surgical revision (34%), mediastinitis (28%), and stroke (28%). The in-hospital and one-year survival rates were 31% and 27% respectively. Myocardial infarction as the cause of the rCS was the only variable independently associated with in-hospital mortality (HR 2.5 [1.3-4.9], p = 0.009).
CONCLUSIONS
The switch from a failing pECMO support to a cECMO as a bridge-to-decision is a possible strategy for a very selected population of young patients with a realistic chance of heart function recovery or heart transplantation. In this setting, cECMO allows patients triage preventing from wasting expensive and limited resources.
背景
外周静脉 - 动脉体外膜肺氧合（pECMO）已成为难治性心源性休克（rCS）的一线治疗设备。一些pECMO并发症可能会排除任何桥接策略，外周至中心ECMO（cECMO）转换可被视为一种决策桥接方式。我们开展这项研究以评估接受外周至中心ECMO转换患者的院内生存率和桥接策略。
方法
这项回顾性单中心研究纳入了2006年2月至2023年1月入住ECMO专用重症监护病房的患者。纳入需要将pECMO转换为cECMO的rCS患者。当cECMO是首个机械循环支持手段时则不纳入患者。
结果
80例患者纳入研究，入院时年龄中位数[IQR25 - 75]为44[29 - 53]岁，女性与男性性别比为0.6。难治性肺水肿是主要的转换原因。30例患者（38%）成功过渡到：心脏移植（n = 16/80，20%）、恢复（n = 10/80，12%）和心室辅助装置（VAD，n = 4/30，5%），而其他患者在cECMO上死亡（n = 50/80，62%）。最常见的并发症是需要肾脏替代治疗（76%）、血胸或心包填塞（48%）、需要手术修正（34%）、纵隔炎（28%）和中风（28%）。院内和一年生存率分别为31%和27%。心肌梗死作为rCS的病因是与院内死亡率独立相关的唯一变量（HR 2.5[1.3 - 4.9]，p = 0.009）。
结论
对于有心脏功能恢复或心脏移植实际机会的特定年轻患者群体，将失败的pECMO支持转换为cECMO作为决策桥接是一种可行的策略。在这种情况下，cECMO允许对患者进行分类，避免浪费昂贵且有限的资源。
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