Bridge-to-recovery strategy using extracorporeal membrane oxygenation for critical pulmonary hypertension complicated with cardiogenic shock
Interactive CardioVascular and Thoracic Surgery
Bridge-to-recovery strategy using extracorporeal membrane oxygenation for critical pulmonary hypertension complicated with cardiogenic shock
Meng-Ta Tsai 2
Chih-Hsin Hsu 0 1
Chwan-Yau Luo 2
Yu-Ning Hu 2
Jun-Neng Roan 1 2
0 Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University , Tainan , Taiwan
1 Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University , Tainan , Taiwan
2 Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University , Tainan , Taiwan
OBJECTIVES: Studies on mechanical-medical bridging for decompensated pulmonary hypertension (PH) are limited. We analysed the outcomes for critical PH patients who underwent extracorporeal membrane oxygenation (ECMO) support using a bridge-to-recovery (BTR) strategy. This study aimed to identify prognostic factors of BTR and evaluate the outcomes of survivors. METHODS: Between 2009 and 2012, 6 patients who received veno-arterial ECMO due to decompensated PH with cardiogenic shock were retrospectively reviewed. All of the patients were managed with an aggressive titration of PH therapies and the optimization of right ventricular (RV) function to wean them off of ECMO. Three of the patients survived to discharge, and the others suffered in-hospital mortality. The differences between their baseline characteristics, ECMO set-up, haemodynamic change and complications were analysed. RESULTS: The average age was 46.67 ± 14.07 years, with a male-to-female ratio of 1:2. The non-survival group exhibited a higher baseline systolic pulmonary artery pressure (127.67 ± 25.81 vs 67.67 ± 24.83 mmHg, P = 0.044) than the survival group before ECMO. All of the nonsurvivors underwent cardiopulmonary-cerebral resuscitation prior to ECMO implantation (100 vs 0%, P = 0.100). The survivors tended to have received suboptimal PH therapies before ECMO and had more readily correctable predisposing factors of right ventricular failure. The non-survivors required a longer duration of ECMO and suffered more end-organ failure or sepsis, although those differences were not statistically significant. Pneumonia developed in 3 of the survivors and caused late mortality in 2 after discharge. CONCLUSIONS: ECMO provides a therapeutic window for the medical stabilization of critically decompensated PH patients. Prompt ECMO intervention before haemodynamic collapse and careful patient selection are critical for successful BTR outcomes.
Pulmonary arterial hypertension; Extracorporeal membrane oxygenation
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INTRODUCTION
Pulmonary hypertension (PH) associated with right ventricular
(RV) failure has a dismal prognosis [1]. Despite improving clinical
outcomes [2], target therapies for PH are inadequate when RV
decompensation or cardiopulmonary failure develops. Moreover,
drug-related vasodilatory effects are intolerable during refractory
cardiogenic shock or cardiopulmonary-cerebral resuscitation (CPCR)
[3]. Consequently, extracorporeal life support (ECLS) is required to
stabilize the haemodynamics and to provide a therapeutic window
to optimize PH medications and RV function. Various types of ECLS,
including right ventricular assist devices (RVADs) [4, 5], veno-arterial
†Contributed equally to this work.
(VA) [6–10] or veno-venous (VV) [3, 8, 9, 11] extracorporeal membrane
oxygenation (ECMO), and pumpless lung assist devices (LADs) [12–15],
in acutely decompensated PH have been studied in recent years.
Current guidelines recommend that patients with an inadequate
response to PH therapies be referred for lung transplantation. In
the current lung allocation scoring system, PH patients may have
low scores at listing, potentiating the prolonged waiting period.
Therefore, mechanical support is important in the time between
listing and transplant surgery [16]. The potential strategies using
ECLS devices for decompensated PH patients include
bridge-totransplant (BTT) and bridge-to-recovery (BTR) approaches. While
target PH therapies are optimized by increasing the titration of
various medications in the BTR strategy [8], most centres rapidly
taper off PH medications and catecholamines in BTT [7, 16].
Although BTT, using either ECMO or pumpless LAD, has been
proved to be advantageous in reducing waiting-list mortality and
improving post-transplant results [13, 17], these approaches are
inevitably limited by donor availability. The BTR strategy, therefore,
should be an option despite the perceived difficulty in weaning off
of ECLS [6, 8, 9]. We report our experience in the management of
critical PH and severe cardiogenic shock with VA ECMO as a BTR
strategy. This study aimed to identify the factors determining
the success of the BTR strategy and to evaluate the long-term
outcomes of survivors.
MATERIALS AND MET (...truncated)