Программа экстракорпоральной мембранной оксигенаций в Казахстане: ближайшие результаты

Экстракорпоральная мембранная оксигенация, международный консорциум (ЭКМО) - процедура продленного искусственного кровообращения и насыщения крови кислородом (оксигенация) вне организма, используемая у пациентов с остро развившейся и потенциально обратимой дыхательной и/или сердечной недостаточностью, лечение которых не поддается максимальной стандартной терапии. Организация экстракорпорального жизнеобеспечения (ELSO) является международным консорциумом центров здравоохранения, который разрабатывает, оценивает и усовершенствует использование ЭКМО. В 2011 г. в нашем центре начала работу программа по обеспечению ЭКМО в Казахстане, а в 2013 г. он вошел в регистр ELSO. В данной статье описывается первый опыт и госпитальные результаты клинического применения ЭКМО в нашем центре. 

Introduction

Extracorporeal membrane oxygenation is an established rescue therapy for severe respiratory failure, cardiogenic shock, and cardiac arrest refractory to conventional therapeutic modalities including ventilatory and high-dose inotropic support [1]. Extracorporeal membrane oxygenation (ECMO) provides days to month of support for patients with respiratory, cardiac, or combined cardiopulmonary failure. For patients with isolated respiratory failure, venovenous (VV) ECMO is typically employed to provide support while the lungs recover. Venoarterial (VA) ECMO is available for cases of cardiac or cardiopulmonary failure. The Extracorporeal Life Support Organization is an international consortium of health care institutions that maintains a registry of ECMO use. As of July 2016, the Extracorporeal Life Support Organization has captured more than 78,000 ECMO implementations, with more than 22,000 in adult patients (Table 1) [2].

Over the last few years, the use of ECMO continues to be an important issue for clinicians, also there has been continued increase in the number of Centers performing ECMO (Fig. 1) and in the amount of pediatric and neonatal use in children with cardiac disease as well as a large increase in the use of ECMO for adult respiratory and cardiac disease (Table 2). In 2011, we initiated the first ECMO program in Kazakhstan. Use of ECMO in newborns and infants is well established, and the modality has been increasingly applied in complex adult populations for indications including acute respiratory failure, acute heart failure, acute coronary syndrome, and cardiogenic shock after cardiac procedures, including percutaneous coronary intervention, cardiac surgery, and heart-lung transplantation [3-9]. In 2012, we initiated experience of applying off-Center ECMO by mobile team employing a novel bedside approach, using echocardiography guided single-site cannulation with a bicaval, dual-lumen catheter.

 This paper describes the initial experience and early outcomes of applying VA-VV ECMO in our Center.

We performed a retrospective analysis of 203 patients, to evaluate clinical outcomes after ECMO Between May 2011 and September 2016. The primary outcome was all-cause mortality. Secondary outcome measures included stroke, bleeding, and acute kidney injury. Stroke was defined as any cerebrovascular event in which either a postoperative iatrogenic complication on the index admission or a primary diagnosis of a hemorrhagic or ischemic cerebrovascular event of any subsequent admission was recorded. This definition excluded transient ischemic attacks. Major bleeding events were identified by a diagnosis of postoperative bleeding, intracerebral hemorrhage, hemopericardium, cardiac tamponade, gastrointestinal hemorrhage, hematuria, hemarthrosis, hemoptysis, epistaxis, or retinal or choroidal hemorrhage during the index admission or requiring subsequent hospital admission within 30 days. Acute kidney injury was defined as a diagnosis of acute renal failure because of nontraumatic causes during the index admission or as a primary diagnosis on any subsequent admission within 30 days.

A total of 203 patients had venovenous and venoarterial extracorporeal membrane oxygenation performed, of these, adult 141 patients at a median age of 47 (22-77) years old, EuroScore II - 7 (4-18), Pregnant - 8. General survival was 56%, adult - 60%, pediatric - 44%, transported patients - 47%. Indication for extracorporeal membrane oxygenation was respiratory failure in 23 (11%) patients, acute coronary syndrome 7 (3.4%) patients: post transplant - patients 19 (9.3)%, postcardiac procedure - patients 134 (66%), acute heart failure in patients 15 (7.3%) (Table 4). Complications on ECMO are very common and as expected it is associated with significant increase in morbidity and mortality (Table 5). Patients outcomes is shown in Fig. 4.

ECMO should be employed early once postcardiotomy cardiogenic shock is suspected. Recent studies report in-hospital survival rates with the use of ECMO ranging from 20% to 50% and mortality rates of 50-70% [7, 9]. In our study, there was an acceptable in-hospital mortality of 42.8%.

This article describes a retrospective analysis of our clinical experience. Despite a relatively high mortality rate, we remain confident that the ECMO is a strong alternative for those who stay refractory for maximal conventional therapy. No doubts, good general postoperative care, proper organization and implementation, continuous learning should be emphasized to prevent the complications of ECMO and to improve patients’ outcomes. Because of the advancement of the ECMO equipment, including oxygenators, biomechanical pumps and heparin coated tubes, the complications could be overcome.

Our analysis has several limitations: it is non randomized, retrospective, single Center research.

Our results reflect findings from previous studies and ELSO registry. Further research in this direction will be helpful to understand outcomes in different clinical subgroups. 

References

5. McCarthy F.H., McDermott K.M., Kini V., Gutsche J.T., Wald J.W., Xie D., Szeto W.Y., Bermudez C.A., Atluri P., Acker M.A., Desai N.D. Trends in U.S. extracorporeal membrane oxygenation use and outcomes: 2002-2012. Semin Thorac Cardiovasc Surg. 2015; 27: 81-8. doi: 10.1053/j.semtcvs.2015.07.005.

9. Feldman D., Pamboukian S.V., Teuteberg J.J., Birks E., Lietz K. International Society for Heart and Lung Transplantation. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary. J Heart Lung Transplant. 2013; 32: 157-87. doi: 10.1016/j.healun.2012.09.013.