Perioperative extracorporeal membrane oxygenation support for pulmonary endarterectomy: A 17-year experience from the UK national cohort

• Published in: The Journal of heart and lung transplantation Vol. 43; no. 2; pp. 241 - 250
• Main Authors: Chia, Alicia X.F., Valchanov, Kamen, Ng, Choo, Tsui, Steven, Taghavi, John, Vuylsteke, Alain, Fowles, Jo-anne, Jenkins, David P.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-02-2024
• Subjects: airway hemorrhage; chronic thromboembolic pulmonary hypertension (CTEPH); Endarterectomy - adverse effects; extracorporeal membrane oxygenation (ECMO); Extracorporeal Membrane Oxygenation - adverse effects; Heart Failure - therapy; Hemorrhage - etiology; Humans; Hypertension, Pulmonary - etiology; Hypertension, Pulmonary - surgery; pulmonary endarterectomy (PEA); pulmonary thromboendarterectomy; reperfusion injury; Reperfusion Injury - complications; Retrospective Studies; right ventricular failure; Treatment Outcome; United Kingdom - epidemiology; United Kingdom; chronic thromboembolic pulmonary hypertension (CTEPH); pulmonary thromboendarterectomy; reperfusion injury; airway hemorrhage; right ventricular failure; extracorporeal membrane oxygenation (ECMO); pulmonary endarterectomy (PEA)
• ISSN: 1053-2498; 1557-3117; 1557-3117
• DOI: 10.1016/j.healun.2023.09.008

Pulmonary endarterectomy (PEA) is the guideline-recommended treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients develop severe cardiopulmonary compromise before surgery, intraoperatively, or early postoperatively. This may result from advanced CTEPH, reperfusion pulmonary edema, massive endobronchial bleeding, or right ventricular (RV) failure secondary to residual pulmonary hypertension. Conventional cardiorespiratory support is ineffective when these complications are severe. Since 2005, we used extracorporeal membrane oxygenation (ECMO) as a rescue therapy for this group. We review our experience with ECMO support in these patients.
This study was a retrospective analysis of patients who received perioperative ECMO for PEA from a single national center from August 2005 to July 2022. Data were prospectively collected.
One hundred and ten patients (4.7%) had extreme cardiorespiratory compromise requiring perioperative ECMO. Nine were established on ECMO before PEA. Of those who received ECMO postoperatively, 39 were for refractory reperfusion lung injury, 20 for RV failure, 31 for endobronchial bleeding, and the remaining 11 were for “other” reasons, such as cardiopulmonary resuscitation following late tamponade and aspiration pneumonitis. Sixty-two (56.4%) were successfully weaned from ECMO. Fifty-seven patients left the hospital alive, giving a salvage rate of 51.8%. Distal disease (Jamieson Type III) and significant residual pulmonary hypertension were also predictors of mortality on ECMO support. Overall, 5- and 10-year survival in patients who were discharged alive following ECMO support was 73.9% (SE: 6.1%) and 58.2% (SE: 9.5%), respectively.
Perioperative ECMO support has an appropriate role as rescue therapy for this group. Over 50% survived to hospital discharge. These patients had satisfactory longer-term survival.