Vo Thin Xuan, Peña Diego, Landau John, Nagpal A Dave
Division of Cardiac Surgery, Department of Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada.
Division of Cardiac Surgery, Department of Surgery, Fundación Valle del Lili, ICESI University, Cali, Valle del Cauca, Colombia.
Can J Cardiol. 2025 Apr;41(4):705-717. doi: 10.1016/j.cjca.2025.01.025. Epub 2025 Jan 30.
Septic shock is associated with significant morbidity and mortality, but a subset of patients with sepsis will experience transient myocardial depression, termed sepsis-associated cardiomyopathy, which markedly increases observed mortality. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) can provide temporary mechanical circulatory support in medically refractory sepsis, survival in patients with VA-ECMO for sepsis has been historically poor. Concerns regarding numerous potential harms associated with VA-ECMO, including further seeding of infection, exacerbation of inflammation and vasoplegia, bleeding, thrombosis, and distal limb ischemia have further tempered enthusiasm in the setting of sepsis. However, there may be a subset of patients with profound sepsis refractory to medical therapy that could potentially derive some benefit from VA-ECMO. This review provides an overview of the pathophysiology, diagnosis, and treatment of sepsis-associated cardiomyopathy and then focuses on the utility of VA-ECMO in this patient population. A summary of the scant published outcomes of VA-ECMO in sepsis-associated cardiomyopathy is provided, followed by a discussion of important management considerations to optimize outcomes in these extremely sick patients, and finally the pros and cons of VA-ECMO in the setting of sepsis are presented. Using available published data and current state-of-the-art practice, we conclude that VA-ECMO may be a reasonable consideration in highly selected patients with low ejection fraction sepsis-associated cardiomyopathy and refractory hypoperfusion in appropriately equipped health care systems, but more supportive data are required before VA-ECMO can be generally recommended in patients with septic shock.
脓毒性休克与显著的发病率和死亡率相关，但一部分脓毒症患者会经历短暂的心肌抑制，即脓毒症相关性心肌病，这显著增加了观察到的死亡率。尽管静脉-动脉体外膜肺氧合（VA-ECMO）可为难治性脓毒症提供临时机械循环支持，但历史上VA-ECMO治疗脓毒症患者的生存率一直很低。对VA-ECMO相关众多潜在危害的担忧，包括感染的进一步播散、炎症和血管麻痹的加重、出血、血栓形成以及远端肢体缺血，进一步削弱了在脓毒症背景下对其应用的热情。然而，可能有一部分药物治疗难治的严重脓毒症患者有可能从VA-ECMO中获益。本综述概述了脓毒症相关性心肌病的病理生理学、诊断和治疗，然后重点关注VA-ECMO在这一患者群体中的应用。提供了VA-ECMO在脓毒症相关性心肌病中极少的已发表结局总结，接着讨论了优化这些重症患者结局的重要管理考虑因素，最后阐述了VA-ECMO在脓毒症背景下的利弊。利用现有的已发表数据和当前的先进实践，我们得出结论，在配备适当的医疗保健系统中，对于高度选择的射血分数低的脓毒症相关性心肌病且难治性低灌注患者，VA-ECMO可能是一个合理的考虑，但在脓毒性休克患者中普遍推荐使用VA-ECMO之前，还需要更多的支持性数据。
