Perioperative Extracorporeal Membrane Oxygenation Based Protocol For Acute Pulmonary Embolectomy: Technique And Preliminary Results
Fabio Ius1, Christian Kühn1, Christine Fegbeutel1, Igor Tudorache1, Mazen Roumieh1, Nurbol Koigeldiyev1, Marius M. Hoeper2, Axel Haverich1, Serghei Cebotari1.
1Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany, 2Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.
Background. At our institution, since 2012, we have applied a protocol using perioperative veno-arterial extracorporeal membrane oxygenation (v-a ECMO) support in all patients with acute pulmonary embolism, in order to reduce the impact of hemodynamic instability. In this study, we present the preliminary results of perioperative ECMO therapy. Methods. We retrospectively reviewed all patients who underwent embolectomy due to acute pulmonary embolism at our institution between 11/2012 and 09/2017. In these patients, v-a ECMO was implanted percutaneously in the femoral vessels before the beginning of the anaesthesia, if it had not already been implanted before. At the end of operation, cardiopulmonary bypass support was switched again to v-a ECMO support, which was continued perioperatively at the intensive care unit.Results. Among the 91 patients who underwent pulmonary thromboendarterectomy between 11/2012 and 09/2017 at our institution, 11 (12%) patients (mean age 64±11 years, all male patients) underwent pulmonary embolectomy for acute embolism. Among these patients, preoperatively, 3 (27%) patients showed concomitant chronic thromboembolic pulmonary artery hypertension, 5 (45%) patients required mechanical ventilation, 6 (55%) patents required v-a ECMO support for cardiogenic shock and 5 (45%) patients had undergone lysis. Mean time under preoperative ECMO support amounted to 3±3 days. V-a ECMO was implanted before beginning of the anaesthesia in the remaining 5 (45%) patients. Intraoperatively, cardiopulmonary and cross clamp times (minutes) amounted to 141±75 and 69±40, respectively. Nine (82%) patients required moderate hypothermic circulatory arrest (13±11 minutes) including 3 patients with extended thromboendarterectomy. Five (45%) patients underwent combined cardiac procedures. One (9%) patient underwent cardiac redo. V-a ECMO was continued after the end of the operation in all patients and weaned successfully after a mean of 4±3 days (range 2-12 days). Six (55%) patients were extubated before ECMO weaning. Two (18%) patients required rethoracotomy for bleeding and 3 (27%) patients required new dialysis treatment (temporary, n=2). No patient showed reperfusion oedema. One (9%) patient died of sepsis 15 days after the pulmonary embolectomy. Conclusions. Our v-a ECMO based protocol for acute pulmonary embolectomy led to stabilization of preoperative compromised haemodynamic. Postoperative ECMO provided good postoperative results in high risk patients.
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