Weaning of extracorporeal membrane oxygenation using continuous hemodynamic transesophageal echocardiography
Weaning of extracorporeal membrane oxygenation using continuous hemodynamic transesophageal echocardiography
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DOI：
10.1016/j.jtcvs.2013.06.055
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发表时间：
2013-12-01
影响因子：
6
通讯作者：
Hirose, Hitoshi
中科院分区：
文献类型：
--
作者：
Cavarocchi, Nicholas C.;Pitcher, Harrison T.;Hirose, Hitoshi
背景：静脉动脉体外膜肺氧合(VAECMO)已被用于深度心源性休克的决策、脑室辅助装置(S)(VADs)或移植。为了评估ECMO脱机期间的心功能和容量状态以及血流动力学，我们开发了一种标准化的脱机方案，由专为持续血流动力学监测而设计的小型经食道超声心动图探头(血流动力学经食道超声心动图[HTEE])引导。我们回顾了我们在HTEE指导下使用这种脱机方案的经验，以评估我们是否可以预测患者的结果。方法：在2011学年，21名接受VA ECMO的患者在HTEE指导下进行了ECMO脱机。持续的HTEE评估左、右室功能和容量状态，同时尝试在标准化方案后撤机ECMO。结果：在21例患者中，6例(29%)左右心功能恢复，并接受了基础冠状动脉疾病的最佳药物治疗或血管重建术；7例(33%)左、右心功能不可恢复；8例(38%)右室恢复但左心功能没有改善。这8名患者接受了左VAD置入术，无一例随后发生严重的右室衰竭。采用我们的标准ECMO脱机方案，HTEE对心脏恢复的阳性预测值为100%(95%可信区间，73%~100%)。结论：HTEE引导的ECMO脱机方案准确地预测了ECMO脱机决策的能力。心脏重症监护室医生可以应用该方案作为标准床边重症监护病房评估的一部分。
Background: Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been used for profound cardiogenic shock to bridge to decision, ventricular assist device(s) (VADs), or transplant. To assess ventricular function and volume status along with hemodynamics during ECMO weaning, we developed a standardized weaning protocol, guided by a miniaturized transesophageal echocardiography probe designed for continuous hemodynamic monitoring (hemodynamic transesophageal echocardiography [hTEE]). We reviewed our experience with this weaning protocol with hTEE guidance to assess if we could predict patient outcomes.Methods: During the academic year of 2011, hTEE-guided ECMO weaning was performed in 21 patients on VA ECMO. Left and right ventricular function and volume status were assessed by continuous hTEE, while attempting to wean ECMO after a standardized protocol. The clinical outcomes, management, and positive predictive value of the device were investigated and analyzed for this cohort of patients.Results: Of the 21 patients, 6 (29%) had left and right ventricular recovery and underwent optimal medical therapy or revascularization for underlying coronary artery disease; 7 (33%) had nonrecoverable left and right ventricular function; and 8 (38%) had right ventricular recovery without improvement of the left ventricular function. These 8 patients underwent left VAD placement; none subsequently developed profound right ventricular failure. The positive predictive value for ventricular recovery by hTEE was 100% using our standardized ECMO weaning protocol (95% confidence interval, 73%-100%).Conclusions: The hTEE-guided ECMO weaning protocol accurately predicted the ability to wean ECMO to decision. This protocol can be applied by cardiac intensivists as a part of standard bedside intensive care unit assessment.