Financial implications of using extracorporeal membrane oxygenation following heart transplantation

OBJECTIVESPrimary graft dysfunction after heart transplant is associated with high morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) can be used to wean patients from cardiopulmonary bypass. This study retrospectively reviews a single-centre experience of post-transplant ECMO in regard to outcomes and associated costs. Open in a separate windowMETHODSBetween May 2006 and May 2019, a total of 267 adult heart transplants were performed. We compared donor and recipient variables, ECMO duration and the incidence of renal failure, bleeding, infection and cost analysis between ECMO and non-ECMO groups.RESULTSECMO support was required postoperatively to manage primary graft dysfunction in 72 (27%) patients. The mean duration of ECMO support was 6 ± 3.2 days. Mean ischaemic times were similar between the groups. There was a significantly higher proportion of ventricular assist device explant to transplant in the ECMO group versus non-ECMO (38.2% vs 14.1%; P < 0.0001). ECMO patients had a longer duration of stay in the intensive care unit (P < 0.0001) and total hospital stay (P < 0.0001). Greater mortality was observed in the ECMO group (P < 0.0001). The median cost of providing ECMO was £18 000 [interquartile range (IQR): £12 750–£24 000] per patient with an additional median £35 225 (IQR: £21 487.25–£51 780.75) for ITU stay whilst on ECMO. The total median cost per patient inclusive of hospital stay, ECMO and dialysis costs was £65 737.50 (IQR: £52 566.50–£95 221.75) in the non-ECMO group compared to £145 415.71 (IQR: £102 523.21–£200 618.96) per patient in the ECMO group (P < 0.0001).CONCLUSIONSPatients with primary graft dysfunction following heart transplantation who require ECMO are frequently bridged to a recovery; however, the medium and longer-term survival for these patients is poorer than for patients who do not require ECMO.     

体外膜肺氧合在心脏移植术后早期移植物功能障碍中的应用

目的  分析体外膜肺氧合(ECMO)在心脏移植术后早期移植物功能障碍(EAD)中的应用效果。方法  回顾性分析614例心脏移植受者的临床资料,根据术后是否使用ECMO分为ECMO组(43例)和非ECMO组(571例)。总结ECMO组受者心脏移植术后ECMO支持治疗情况,比较两组受者的围手术期情况和远期预后。结果  43例ECMO支持受者中,17例因出血进行开胸探查,10例出现感染,4例出现下肢静脉血栓,1例出现脑卒中。26例受者成功脱离ECMO后康复出院,6例受者ECMO支持期间死亡,6例受者ECMO脱机后死亡,5例受者因无法脱离ECMO而接受再次移植,再次移植后仅1例存活。与非ECMO组比较,ECMO组术中体外循环时间较长,术后需要主动脉内球囊反搏(IABP)、肾功能不全需要透析、再次开胸止血、感染、机械通气时间≥96 h和气管切开比例较高,术后重症监护室(ICU)入住时间较长(均为P < 0.05)。ECMO组受者出院生存率和90 d生存率分别为63%和96%,低于非ECMO组的97%和100%,差异均有统计学意义(均为P < 0.05)。生存分析结果显示,ECMO组受者的远期生存率低于非ECMO组(P < 0.05); 当排除心脏移植术后90 d内死亡的受者后,两组之间的远期生存率差异无统计学意义(P > 0.05)。结论  ECMO是治疗心脏移植术后EAD有效的方法。使用ECMO的受者心脏移植术后的早期生存率低于不使用ECMO的受者,而顺利度过心脏移植术后90 d远期生存率差异无统计学意义。     

体外膜肺氧合技术在心脏移植不同时期的应用

目的 探讨体外膜肺氧合技术(ECMO)在心脏移植术前辅助、术中替代体外循环及术后辅助治疗的临床应用效果.方法 对心脏移植术前过渡、术中代替常规体外循环以及术后心功能衰竭辅助治疗中使用ECMO技术患者的临床资料进行回顾分析.结果 3例等待心脏移植的患者术前应用ECMO 5～8 d,其中2例患者在等待供心的过程中发生多器官功能衰竭而死亡;1例患者成功接受心脏移植,术后顺利撤除了ECMO.12例在心脏移植术中应用了ECMO代替常规体外循环技术,均顺利完成手术,术后持续应用ECMO辅助的时间平均为(38±14)h,1例患者因发生多器官功能衰竭死亡,其余11例患者均痊愈,顺利出院,无患者发生右心功能衰竭和三尖瓣返流等心脏移植术后常见的并发症.心脏移植术后由于严重右心功能衰竭接受ECMO辅助治疗的患者有10例,起始时间为返回监护室后2 h至2 d,持续时间为43～176 h,其中7例患者痊愈,顺利出院,1例因发生严重感染而死亡,2例因发生多器官功能衰竭而死亡.以上死亡患者的死亡原因均与ECMO的出血或血栓形成等并发症无关.结论 尽早应用ECMO可以使等待心脏移植的心功能衰竭患者有效地过渡到心脏移植;术中应用ECMO替代常规体外循环技术可以更好地保护供心,有利于缺血时间较长供心的功能恢复,提高心脏移植手术成功率;术后患者出现右心功能衰竭时,应用ECMO有良好的辅助治疗效果.

Abstract：

Objective To investigate the clinical results of extracorporeal membrane oxygenation (ECMO) technique during the peri-operative heart transplantation. Methods The clinical data of heart transplantations supported by the ECMO were retrospectively analyzed, including during the bridge to transplant, working as routine bypass in the operation room, and supporting the heart failure after surgery. Results Three 3 cases were supported with ECMO to extend the waiting time: 2cases died of multi organ failure during the waiting, and the third one received the heart transplant and the ECMO was successfully removed. Totally 12 cases of heart transplantation received the modified open style ECMO techniques replacing the routine bypass. The ECMO was removed after assistance for (38 ± 14) h. All the recipients except one death recovered well without right ventricular failure or obvious tricuspid regurgitation which was common after heart transplantation. Ten cases received ECMO support for the heart failure after the transplant. The initial application time ranged from 2 h to 2 days and lasted 43～176 h. One died of infection and two died of multi organ failure nothing to do with ECMO application and other 7 discharged with NYHA Ⅰ/Ⅱ cardiac function. Conclusion Early use of ECMO could safely bridge the heart failure patients to the transplant. Replacing the routine with ECMO techniques in the heart transplantation could get good myocardial protection results even with long cold ischemic time and improve the cardiac function recovery. For the heart failure patients after the surgery the ECMO could afford good support effect.     

体外膜肺氧合在边缘供心移植中的临床应用研究

探讨体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)用于长时间冷缺血(long cold ischemic time,LCIT)供心心脏移植术的临床疗效.方法 2005年2月至2009年4月,11例患者[ECMO环路(intraoperative ECMO,i-ECMO)组]接受LCIT 超过7 h的供心移植,手术采用i-ECMO 进行心肺分流术,术毕直接转为ECMO辅助.同期有11例患者[心肺分流术(standard cardiopulmonary bypass,s-CPB)组,s-CPB组]行冷缺血少于7 h的心脏移植手术,术中常规s-CPB,术后接受了ECMO辅助.比较两组的ECMO的总体撤机率、ICU停留时间、浓缩红细胞输注量、左心室射血分数(LVEF)、住院费用、围手术期生存率、术后1年生存率,并了解ECMO相关并发症.结果 i-ECMO组和s-CPB组供心缺血时间分别为422~485(平均448) min、110~400(平均218)min,两组间比较差异有统计学意义(P<0.01).i-ECMO组中10例患者(91%)成功撤离ECMO并无出院前死亡,1例死于术中大出血(与ECMO无关),s-CPB组中9例(82%)成功撤离ECMO.心脏移植应用ECMO的总体撤机率为86%.两组术后30 d(围手术期)和术后1年的生存率分别为91%和82%、73% 和64%,两组比较差异均无统计学意义(P>0.05).i-ECMO组的ICU停留时间、浓缩红细胞输注量以及住院花费均显著低于对s-CPB组(均为P<0.05).i-ECMO组的入院和出院LVEF分别为0.23±0.06、0.65±0.12,s-CPB组相应为0.25±0.10、0.66±0.06,两组出院时LVEF均较术前明显升高,但两组比较差异无统计学意义(P>0.05).ECMO相关并发症及处理:5例患者(23%)因低心排量而应用了主动脉内球囊反搏(IABP),其中3例为成功撤离ECMO的病人,2例为未能撤离ECMO者;6例(27%)患者由于肾功能不全接受了持续肾替代治疗(CRRT),其中2例为成功撤离ECMO,4例为未能撤离ECMO者.结论 用边缘供心进行心脏移植术时,术中利用i-ECMO、术毕转为ECMO辅助可以为LCIT的供心提供早期、持续和有效的循环支持,从而在相当程度上改善此类边缘供心的移植成功率.同时,该研究方法 还具有ICU停留时间短,浓缩红细胞输注量低和显著节省费用的优点.     

体外膜氧合机械辅助在心脏移植手术中的应用

目的回顾性研究接受心脏移植手术并采用体外膜氧合(ECMO)辅助支持治疗的患者,总结临床经验,为进一步推广提供参考。方法收集中国医学科学院阜外心血管病医院接受心脏移植手术并采用ECMO支持受者的临床资料,分析受者围手术期ECMO应用情况,统计ECMO支持时间,合并使用主动脉内球囊反搏(IABP)的情况,并发症发生情况等临床资料。采用SPSS23.0软件处理,正态分布采用独立样本Student's test,非正态分布采用非参数检验Mann-Whitney U test。分类资料的组间比较采用χ2检验或Fisher确切检验法。结果所有ECMO支持模式均为静脉-动脉ECMO模式(V-A ECMO)。有8例受者成功使用ECMO过渡到心脏移植。使用ECMO的心脏移植受者中61例(89.7%)成功脱离ECMO机械辅助,48例(70.5%)存活出院。出血、术后急性肾功能不全、肺部感染等并发症是心脏移植ECMO循环支持过程中最多见的并发症。在手术室早期建立ECMO辅助循环的心脏移植受者脱机率和存活率分别为95.6%和84.4%,而在ICU床旁建立ECMO的受者脱机率和存活率分别为72.2%和27.8%,早期使用ECMO结果更好。结论ECMO机械辅助循环能对心脏移植受者提供有效的循环、呼吸功能支持,使得受者平稳渡过移植手术围术期。提倡早期、同期联合应用IABP增加重要器官的灌注,改善受者的预后,获得良好的转归。     

The early evaluation of survivors after extracorporeal membrane oxygenation for neonatal pulmonary failure

Excluding mortality data, there is little information regarding patients' development after extra corporeal membrane oxygenation (ECMO). In six of nine neonates surviving ECMO for predictably fatal pulmonary failure, examination 15 to 21 months afterward showed (1) physical growth and development, normal in six; (2) chest x-ray, normal pulmonary parenchyma; (3) average arterial blood gases, PO2 80, Pco2 35, pH 7.35; (4) echocardiogram, normal, without evidence of pulmonary hypertension; (5) cerebrovascular dopplers, normal ophthalmic artery flow in five patients, retrograde in one; (6) CT scan, EEG, neurologic survey, normal in five, cerebral atrophy in one patient who had an air embolus during decannulation; (7) psychologic examination, normal in all. This early evaluation of ECMO survivors should encourage its further application in those newborns who would otherwise die.     

体外膜肺氧合在肺移植麻醉中的应用

目的 总结肺移植麻醉中体外膜肺氧合(extracorporeal memberane oxygenation,ECMO)辅助的适应证及术中运用ECMO支持的经验.方法 58例终末期肺病患者在麻醉诱导气管插管后,常规给予非术侧单肺通气30 min,监测肺动脉压(PAP)、氧分压(PaO2)、二氧化碳分压(PaCO2)、肺泡气·动脉氧分压差(PA-aO2)和呼吸力学等指标,根据监测指标调节机械通气参数,必要时行手控通气.17例患者分别因肺动脉高压、低氧血症和高碳酸血症而给予ECMO辅助,转流期间维持激活凝血时间(ACT)160秒～200秒,流量控制在1.8 L·m-2·min-1～2.5 L·m-2·min-1.结果 所有患者ECMO转流后PAP及PaCO:下降明显,氧合改善.麻醉伞程生命体征平稳.手术经过顺利.结论 ECMO是肺移植术中肺辅助的有效手段,可提高肺移植手术的麻醉成功率.原发性肺动脉高压、肺纤维化合并肺动脉高压、严重的低氧血症和高碳酸血症是肺移植术中ECMO转流的适应证.     

心脏移植前采用体外膜肺氧合循环支持过渡二例

目的：探讨等待心脏移植患者发生心源性休克时采用体外膜肺氧合（ECMO）循环支持过渡的可行性和有效性。方法：2例患者在等待心脏移植期间发生心源性休克，1例为限制型心肌病，另1例为扩张型心肌病，并发肝功能异常，药物治疗均无法控制心力衰竭和呼吸衰竭，遂紧急使用ECMO支持，等待心脏移植。使用Medtronic成人ECMO系统，采用股动脉、股静脉插管，ECMO系统使用肝素涂层表面和离心泵，流量30～50ml·kg^-1·min，激活全血凝固时间维持在160s左右，血温维持在36～37℃。流量随心肺功能改善情况进行调整，支持期间监测动脉血气、血浆游离血红蛋白、血小板、出血及凝血指标，以及股动脉插管侧下肢血液循环情况。结果：经ECMO支持后，患者的血流动力学稳定，血气各指标改善，循环、呼吸平稳，X线显示双肺清晰，肝功能异常的1例肝功能好转。ECMO支持期间未发生严重的并发症。2例患者分别支持了5d和3d，均顺利过渡到心脏移植，术后心功能Ⅰ级，未发生排斥反应，患者痊愈出院。结论：等待心脏移植患者发生心源性休克时，可采用ECMO循环支持过渡，安全、有效。     

Institutional experience with extracorporeal membrane oxygenation in lung transplantation.

Background: Extracorporeal membrane oxygenation (ECMO) is currently accepted in lung transplantation either to bridge patients to transplantation or to treat postoperatively arising severe primary graft failure. Based on promising initial experiences we have since 2001 implemented ECMO as the standard of intraoperative extracorporeal support in lung transplantation (LuTX) patients with haemodynamic or respiratory instability with the potential to prolong ECMO support into the perioperative period. The aim of this paper is to summarise our total experience with the use of ECMO in LuTX. Methods: We retrospectively reviewed all 306 patients undergoing primary lung transplantation from 1/2001 to 1/2006 with regard to the different forms of ECMO use. Results of all patients requiring ECMO were compared to those without ECMO during the observation period. Results: ECMO was used in 147 patients in total. Two patients were bridged to transplantation. A total of 130 patients received intraoperative ECMO support. In 51 of these patients ECMO was prolonged into the perioperative period. Five of these patients required ECMO support again in the postoperative period due to graft dysfunction. Contrary cardiopulmonary bypass was used in 27 patients mainly with concomitant cardiac defects. Eleven of these patients needed therapeutic ECMO in the further course. A total of 149 patients without relevant risk factors were transplanted without any intraoperative extracorporeal support. Six of these patients required ECMO support in the postoperative period for treatment of primary graft dysfunction. Overall 3-month, 1-year and 3-year survival rates were 88.6%, 82.1% and 74.63%. The mentioned survival rates were 85.4%, 74.2% and 67.6% in the intraoperative+/-prolonged ECMO group; 93.5%, 91.9% and 86.5% in the no support group and 74.0%, 65.9% and 57.7% in the CPB group. Conclusion: ECMO is a valuable tool in lung transplantation providing the potential to bridge patients to transplantation, to replace CPB with at least equal results and to overcome severe postoperative complications. Favourable survival rates can be achieved despite the fact that ECMO is used in the more complex patient population undergoing lung transplantation as well as to overcome already established severe complications.     

Peripheral extracorporeal membrane oxygenation (ECMO) in patients with posttransplant cardiac graft failure

INTRODUCTION: We sought to report the usefulness of extracorporeal membrane oxygenation (ECMO) in heart transplant patients. PATIENTS: Between March 2002 and August 2004, 14 heart transplant patients (11 men and three women, 36 +/- 15 years old, range = 12 to 50) with primary graft failure underwent peripheral ECMO implantation. Three patients had pulmonary hypertension and three had been transplanted with hearts from marginal donors. At the time of implantation, all were in severe cardiogenic shock despite maximal inotropic support. In six patients, the ECMO was implanted in the operating room since cardiopulmonary bypass could not be weaned. In the eight remaining patients, ECMO was implanted in the intensive care unit, during the first 48 hours in seven cases. In one patient, implantation was performed during external resuscitation. In all cases, femoral vessels were canulated using the Seldinger technique after anterior wall exposure. Distal arterial perfusion of the lower limb was systematically used. RESULTS: Pump outflow was high enough in all the cases (mean: 2.6 +/- 0.2 L/min/m(2)). Three patients died on circulatory support. One patient was implanted with a total artificial heart after a few hours and another one underwent unsuccessful emergent retransplantation. Nine patients were weaned from ECMO after a mean duration of 5 +/- 2.5 days. Among them, one died of infection at 10 days after weaning and seven others were discharged to rehabilitation centers. CONCLUSION: Fast operating room or bedside implantation of a peripheral ECMO allows the physician to stabilize the hemodynamic status of patients with cardiac graft failure, potentially leading toward myocardial recovery.     

Risk stratification of patients listed for heart transplantation while supported with extracorporeal membrane oxygenation

ObjectivesExtracorporeal membrane oxygenation (ECMO) is used to support patients in severe cardiogenic shock. In the absence of recovery, these patients may need to be listed for heart transplant (HT), which offers the best long-term prognosis. However, posttransplantation mortality is significantly elevated in patients who receive ECMO. The objective of the present study was to describe and risk-stratify different profiles of patients listed for HT supported by ECMO.MethodsPatients listed for HT in the United Network for Organ Sharing database were analyzed. The primary outcome was 1-year survival and was assessed in patients bridged to transplant with ECMO (ECMO_BTT) and patients who were previously supported on ECMO but had it removed before HT (ECMO_REMOVED).ResultsAmong 65,636 adult candidates listed for HT (between 2001 and 2017), 712 were supported on ECMO, 292 of whom (41%) underwent HT (ECMO_BTT, n = 202; ECMO_REMOVED, n = 90). Most of the patients with ECMO_REMOVED were transplanted with a ventricular assist device. In ECMO_BTT, recipient age (each 10-year increase), time on the waitlist (both defined as minor risk factors), need for dialysis, and need for mechanical ventilation (both defined as major risk factors) were independent predictors of mortality. ECMO_REMOVED and ECMO_BTT with no risk factors showed 1-year survival comparable to that in patients who were never supported on ECMO. Compared with patients who were never on ECMO, patients in ECMO_BTT group with minor risk factors, 1 major risk factor, and 2 major risk factors had ~2-, ~5-, and >10-fold greater 1-year mortality, respectively (P < .05).ConclusionsThe HT recipients in the ECMO_REMOVED and ECMO_BTT groups with no risk factors showed similar survival as the HT recipients who were never supported on ECMO. In the ECMO_BTT group, posttransplantation mortality increased significantly with increasing risk factors.     

成人体外膜肺氧合循环支持19例

目的总结成人临床应用体外膜肺氧合（ECMO）的经验、教训。方法2004年12月至2006年4月对19例成人实施ECMO，男14例，女5例；年龄19～72岁，平均48．8岁；体重37～100kg，平均69．2kg。内科急性心肺衰竭4例，术后心肺衰竭15例。使用Medtmnic成人ECMO配套系统，经股动、静脉插管行心肺辅助。结果10例（52．6％）顺利出院，9例（47．4％）死亡，其中6例未能脱机，EC2V10成功脱机13例（68．4％），其中3例脱机后未能得到进一步有效治疗而死亡。EC2V10支持11～196h，平均83．3h。单一膜肺使用寿命40～134h。结论EC2V10可以作为临床难治性心肺衰竭的有效辅助手段，使危重症病人度过危险期，为进一步治疗争取宝贵的时间。     

A bridge-to-bridge approach to heart transplantation using extracorporeal membrane oxygenation and total artificial heart

BackgroundThis study aims to describe the outcomes after heart transplantation using a bridge-to-bridge strategy with a sequence of extracorporeal membrane oxygenation (ECMO) support followed by temporary total artificial heart implantation (TAH-t).MethodsA retrospective, multicenter analysis of 54 patients who underwent TAH-t implantation following an ECMO for cardiogenic shock was performed (ECMO-TAH-t group). A control group of 163 patients who underwent TAH-t implantation as a direct bridge to transplantation (TAH-t group) was used to assess this strategy's impact on outcomes.ResultsFifty-four patients, averaging 47 ± 13 year old, underwent implantation of a TAH-t after 5.3 ± 3.4 days of ECMO perfusion for cardiogenic shock. In the ECMO-TAH-t group, 20 patients (20/54%; 37%) died after TAH-t implantation and 57 patients (57/163%; 35%) died in the TAH-t group (Gray test; P = .49). The top 3 causes of death of patients on TAH-t support were multisystem organ failure (40%), sepsis (20%), and neurologic events (20%). Overall, 32 patients (32/54%; 59%) underwent heart transplantation in the ECMO-TAH-t group compared with 106 patients (106/163%, 65%) in the TAH-t group (P = .44). No significant difference in survival was observed at 6 months, 1 year, and 3 years after heart transplant (ECMO-TAH-t group: 94%, 87%, and 80% vs 87%, 83%, and 76% in the TAH-t group, respectively). Deterioration of liver function (bilirubin, aspartate transaminase, and alanine aminotransferase levels on TAH-t) was associated with increased mortality before heart transplant in both groups.ConclusionsSequential bridging from ECMO to TAH-t followed by heart transplantation is a viable option for a group of highly selected patients.     

Pediatric extracorporeal membrane oxygenation in posttraumatic respiratory failure

The leading cause of death in the pediatric population in the United States is trauma. A retrospective review of patients treated with extracorporeal membrane oxygenation (ECMO) for traumatic respiratory failure was performed. Eight children were treated at the Ochsner Medical Foundation and additional data on six children were available from the National Registry. Six children developed respiratory failure as a result of blunt trauma and eight as a result of near drowning. Standard venoarterial ECMO was used with a circuit very similar to that used in neonatal ECMO. Vascular access was via the common carotid artery and the internal jugular vein. Ventilatory support was weaned to minimal settings during ECMO. Central hyperalimentation and systemic antibiotics were used in all of the cases. Four of six children survived in the blunt trauma group; three of eight children survived in the near drowning group. Although significant conclusions cannot be drawn from a small group of patients the average pre-ECMO PO2 for survivors was 87 mm Hg, whereas for nonsurvivors the average PO2 was only 46 mm Hg. Ventilatory support for both groups was not remarkably different, and the average PCO2 was lower in the nonsurvivor group. The cause of death in this group of patients is usually multisystem organ failure. In the four patients treated at Ochsner who did not survive, all had positive blood cultures and presumed systemic sepsis. ECMO has been demonstrated to be very successful in neonatal respiratory failure. Predicting mortality and morbidity in pediatric respiratory failure has been more difficult.(ABSTRACT TRUNCATED AT 250 WORDS)