Postcardiotomy ECMO Support after High-risk Operations in Adult Congenital Heart Disease
Postcardiotomy ECMO Support after High-risk Operations in Adult Congenital Heart Disease
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DOI：
10.1111/chd.12396
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发表时间：
2016-11-01
影响因子：
0.3
通讯作者：
Schears, Gregory J.
中科院分区：
文献类型：
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作者：
Acheampong, Benjamin;Johnson, Jonathan N.;Schears, Gregory J.
背景高危成人先天性心脏病（ACHD）患者的心脏手术可能需要机械循环支持（MCS），如体外膜肺氧合（ECMO）或主动脉内球囊反搏（IABP），以恢复心肺系统。我们回顾了2001年1月至2013年12月在我们机构接受心切开术后需要MCS的所有ACHD患者的记录。在研究期间，ACHD患者进行了2264例（平均年龄39.1岁，女性相似，54.1%）手术，其中24例（1.1%）需要术后MCS（14例男性;中位年龄41岁，范围22-75）。术前，24例患者的平均全身心室射血分数为47%（范围10-66%）;这些患者中有72%为NYHA III/IV级心力衰竭。常见的基础诊断包括室间隔完整的肺动脉闭锁（20%）、法洛四联症（16%）、Ebstein畸形（12%）、cc-TGA（12%）、间隔缺损（12%）和其他（28%）。进行的手术是瓣膜手术（有/无迷宫）（58.2%），Fontan转换（21%），冠状动脉旁路移植术与瓣膜手术（12.5%）和心脏移植（8.3%）。MCS的适应症为左侧（全身）心力衰竭（32%）、右侧（肺下）心力衰竭（24%）、双心室心力衰竭（36%）、持续性心律失常（4%）和低氧血症（4%）。42%的患者仅接受ECMO;在第二组中，尝试使用IABP，随后开始ECMO。MCS的平均持续时间为8.4天（范围0.8-35.4）。常见的疾病包括凝血功能障碍（60%）、肾功能衰竭（56%）和心律失常（48%）。总体而言，46%的患者存活至出院。死亡原因要么是多器官衰竭，要么是潜在的心脏病;败血症是一名患者死亡的主要原因。存活者的中位随访时间为41个月（最长106个月）。8例晚期存活者NYHA心功能分级均为I/II级。在高危ACHD患者进行复杂手术后，可能需要MCS。尽管发病率很高，但仍有近一半的患者存活至出院。
Background. Cardiac operations in high-risk adult congenital heart disease (ACHD) patients may require mechanical circulatory support (MCS), such as extracorporeal membrane oxygenation (ECMO) or intraaortic balloon pump (IABP), to allow the cardiopulmonary system to recover.Methods. We reviewed records for all ACHD patients who required MCS following cardiotomy at our institution from 1/2001 to 12/2013.Results. During the study period, 2264 (mean age 39.1 years, females similar to 54.1%) operations were performed in ACHD patients of whom 24 (1.1%) required postoperative MCS (14 males; median age 41 years, range 22-75). Preoperatively the 24 patients had a mean systemic ventricular ejection fraction of 47% (range 10-66%); 72% of these patients were in NYHA class III/IV heart failure. The common underlying diagnoses included pulmonary atresia with intact ventricular septum (20%), tetralogy of Fallot (16%), Ebstein anomaly (12%), cc-TGA (12%), septal defects (12%), and others (28%). Operations performed were valvular operations with/without maze (58.2%), Fontan conversion (21%), coronary bypass grafting with valvular operations (12.5%), and heart transplant (8.3%). Indications for MCS were left-sided (systemic) heart failure (32%), right-sided (subpulmonary) heart failure (24%), biventricular heart failure (36%), persistent arrhythmia (4%), and hypoxemia (4%). Forty-two percent were placed on ECMO only; in the second group, IABP was attempted and subsequently followed by ECMO initiation. The mean duration of MCS was 8.4 days (range 0.8-35.4). Common morbidities included coagulopathy (60%), renal failure (56%), and arrhythmia (48%). Overall, 46% of patients survived to hospital discharge. Deaths were due to either multi organ failure or the underlying cardiac disease; sepsis was the primary cause of death in one patient. Median follow-up for survivors was 41 months (maximum 106 months). NYHA functional class was I/II in all 8 late survivors.Conclusions. Following complex operations in high-risk ACHD patients, MCS may be required. Despite significant morbidity, nearly half of patients survive to hospital discharge.