Kumar Reha, Amadio Jennifer M, Luk Adriana C, Bhaskaran Abhishek, Ha Andrew C T
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
Can J Cardiol. 2025 Apr;41(4):645-655. doi: 10.1016/j.cjca.2024.12.018. Epub 2024 Dec 17.
Patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO) are at high risk for ventricular arrhythmias due to derangements in myocardial perfusion, hemodynamics, and heightened catecholamine states. Existing data on the management and outcomes of patients with electrical storm or refractory ventricular tachycardia/fibrillation (VT/VF) treated with VA-ECMO are primarily derived from retrospective observational studies. Typical survival rates are in the range of 40%-50%, with 15%-20% of patients undergoing VT ablation and 30%-40% of patients requiring advanced heart failure therapies (cardiac transplant or durable left ventricular assist device). Similarly, there is a paucity of published data on VT/VF management for patients while on VA-ECMO, as these data are largely extrapolated from patients with electrical storm. Although many of the treatment principles (identifying reversible causes, antiarrhythmic drugs, VT ablation, and reduction of adrenergic tone) are translatable, several aspects require special consideration when managing VT/VF in the VA-ECMO patient population. Among carefully selected patients on VA-ECMO who underwent VT ablation, reported recurrence rates were ∼ 30% and a sizeable proportion of them (30%-40%) required advanced heart failure therapy as an exit strategy. In addition, there are specific issues that require consideration for patients on VA-ECMO who undergo VT ablation, such as vascular access, ECMO access site complications, and bleeding due to systemic anticoagulation. Optimal management of VT/VF in this patient population requires ongoing reassessment and dialogue among electrophysiology, heart failure, and critical care specialists. Additional research is needed to better inform the care of this very high-risk patient population.
接受静脉-动脉体外膜肺氧合（VA-ECMO）治疗的患者，由于心肌灌注紊乱、血流动力学改变以及儿茶酚胺水平升高，发生室性心律失常的风险很高。关于接受VA-ECMO治疗的电风暴或难治性室性心动过速/心室颤动（VT/VF）患者的管理及预后的现有数据，主要来自回顾性观察研究。典型的生存率在40%-50%之间，15%-20%的患者接受VT消融治疗，30%-40%的患者需要接受晚期心力衰竭治疗（心脏移植或耐用的左心室辅助装置）。同样，关于VA-ECMO治疗期间患者VT/VF管理的已发表数据也很匮乏，因为这些数据大多是从电风暴患者中推断出来的。尽管许多治疗原则（确定可逆病因、抗心律失常药物、VT消融以及降低肾上腺素能张力）是可转化的，但在管理VA-ECMO患者群体的VT/VF时，有几个方面需要特别考虑。在精心挑选的接受VT消融的VA-ECMO患者中，报告的复发率约为30%，其中相当一部分患者（30%-40%）需要接受晚期心力衰竭治疗作为出院策略。此外，对于接受VT消融的VA-ECMO患者，还有一些特定问题需要考虑，如血管通路、ECMO通路部位并发症以及全身抗凝导致的出血。对该患者群体的VT/VF进行最佳管理，需要电生理、心力衰竭和重症监护专家之间持续进行重新评估和沟通。需要开展更多研究，以便为这一极高风险患者群体的护理提供更充分的信息。
