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Procedural and Short-term Effectiveness of External Membrane Pulmonary Oxygenation in Percutaneous Coronary Intervention for Complex Coronary Artery Disease: A case series.
作者:郑金刚[1] 
单位:中日友好医院(中日医院)[1]  
文章号:W131952  
2018/11/23 9:35:23    
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Authors and Emails:

  Zheng Zheng*     drzhengz@163.com 

  Xiaofei Liu*       lxfei1219@126.com 

  Zhe Dong         sdwhdz@163.com

  Hu Zhang         zhang2005hu@sina.com

  Zhiwei Han        hzw414@163.com

  Dongliang Fu      fudongliang312@163.com

  Wenhua Peng     13810856080@163.com

  Jingang Zheng     mdjingangzheng@163.com


  Department of Cardiology, China-Japan Friendship Hospital of Ministry of Health, Beijing 100029, China.


  Correspondence should be addressed to Jingang Zheng. 

  Department of Cardiology, China-Japan Friendship Hospital of Ministry of Health

  Beijing, China.

  Postcode, 100029

  E-mail, mdjingangzheng@163.com.


Author contributions

  *These authors contributed equally to this work and should be considered co-first authors.


  Procedural and Short-term Effectiveness of External Membrane Pulmonary Oxygenation in Percutaneous Coronary Intervention for Complex Coronary Artery Disease: A case series


Abstract

  Objective: To investigate the short-term effectiveness of extracorporeal membrane oxygenation (ECMO)-supported percutaneous coronary intervention (PCI) for patients with complex coronary artery lesions. Methods and results: Data on baseline and procedural characteristics and in-hospital and 6 months of follow-up outcomes were retrospectively collected on 6 consecutive patients with complex coronary artery disease who underwent PCI under ECMO support at our center from July 2016 to October 2017. In the 6 patients studied, PCI with implantation of 2-3 stents was successfully performed with EMCO support (mean duration, 10.5 [range, 6-26] hours) without malignant arrhythmia or other complications. In-hospital rate of ECMO site-related complications was 33.3% (one infection and one deep vein thrombosis), and in-hospital survival rate was 100%. 6 months of follow-up survival rate was 66.7% (2 cases death secondary to severe heart failure in 6 cases).Conclusion: ECMO appears to provide effective circulatory support during PCI of complex coronary artery lesions; however, its safety and longer-term outcomes warrant further study.


  Key words: Extracorporeal Membrane Oxygenation; Complex Coronary Artery Lesions; Percutaneous Coronary Intervention


Conflict of Interest

  All the authors listed have disclosed that they do not have any conflict of interest.


Introduction

  Percutaneous coronary intervention (PCI) for complex coronary artery disease is associated with a higher risk of serious and even fatal complications such as malignant arrhythmia, cardiopulmonary arrest and cardiac tamponade. Coronary artery bypass grafting therefore is a better choice than PCI; however, patients who experience restenosis after bypass grafting or have poor cardiac function and are deemed unsuitable candidates for surgery might benefit from PCI if circulatory function can be stabilized[1-4].As an alternative to intra-aortic balloon counterpulsation which has not proven beneficial for PCI for complex coronary lesions [5, 6], external membrane pulmonary oxygenation (ECMO) by allowing to extracorporeally oxygenate blood would be expected to increase coronary perfusion pressure and improve myocardial blood supply, thereby reducing the burden on the heart and promoting its functional recovery. Based on the favorable two-decade long experience with use of ECMO in rescue of patients with respiratory and circulatory failure [7-9], and on more recent studies on ECMO-supported PCI of patients with acute myocardial infarction complicated with cardiogenic shock[10, 11], our center has conducted ECMO-supported PCI of patients with complex coronary lesions since July 2016 and we here present data on procedural and in-hospital effectiveness in the 6 cases treated over the first 2 years.


2.Methods

  2.1Study population

  We retrospectively collected data on 6 consecutive patients who, from July 2016 to October 2017, underwent at our center ECMO-supported PCI for complex coronary artery disease, i.e., triple-vessel disease and/or left main coronary stenosis with calcification; stenosis degrees>75% to total occlusion; wall contraction abnormalities under UCG with left ventricular ejection fraction <50%; frequent angina pectoris; and/or history of coronary artery bypass grafting and unable or refusing to undergo surgery. Study participants provided informed consent and this retrospective review conformed to institutional guidelines and those of the American Physiological Society.


  2.2ECMO-supported PCI

  At least for 7 days before ECMO-supported PCI, patients were on daily oral aspirin 100mg and clopidogrel 75mg. Before the procedure, 4 units of packed red blood cells and 400mL fresh frozen plasma were prepared for use for intraprocedural transfusion and ECMO removal. For PCI, a sheath was inserted via right radial/femoral artery by the Seldinger puncture method, and coronary lesions were treated by atherectomy and/ orstent implantation. During PCI, patients received 9000U UFH via artery.


  The 6 patients studied received ECMO via femoral arteriovenous catheterization (V-A ECMO). The ECMO circuitry and instrumentation (Medtronic, Inc., St. Paul, MN, USA) included a centrifugal machine (Medtronic-550), customized heparin coating integrated package pipeline (including pump and membrane oxygenator), heparin coating femoral arteriovenous catheterization, air-oxygen mixer, heater cooler units, and MAQUET hemoconcentrators. Pump flow was 40-50mL (kg/min). If hemodynamic instability or ventricular arrhythmia developed, flow was increased to 3L/min to preserve tissue perfusion. Mean arterial pressure was maintained at 50-70mmHg; oxygen concentration from the air-oxygen mixer at 50-60%,现金网:ECMO ventilation-to- blood flow ratio at 0.6-1:1, and PCO2 during ECMO support at 35-45mmHg. After PCI, if the patient was stable with good circulatory function, flow was reduced or patient was weaned off ECMO. Ten minutes after weaning, ECMO was removed. Two patients were transferred to the intensive care unit with ECMO, which was removed upon circulatory function recovery. Successful ECMO weaning was defined as stable circulatory function for 72 hours after weaning and without any discomfort.  


Results

  Baseline characteristics of patients are summarized in Table 1. Mean age for the 6 patients studied was 70.5 years; 50% were male; 83.3% diabetic; 50% hypertensive; 66.7% had chronic renal insufficiency (serum creatinine level before PCI: mean, 188.67; range, 65-411 μmol/L);66.7% had history of thromboembolic disease and 16.76% of prior CABG; mean left ventricular ejection fraction was 46.5% (range, 30-63%); and 83.3% of patients had heavily calcified lesions treated by atherectomy.


  As shown in Tables 2 and 3, in the 6 patients studied, PCI with implantation of 2-3 stents was successfully performed under EMCO support (mean duration, 10.5 [range, 6-26] hours) without malignant arrhythmia or other complications. In-hospital rate of ECMO site-related complications was 33.3% (one infection and one deep vein thrombosis) and in-hospital survival rate was 100%. For left ventricular ejection fraction, mean value in four patients after PCI was 48.3%; and the maximal individual increase was 19% while the average increase was 7.75%. The survival rate was 66.7% (2 cases death secondary to severe heart failure in 6 cases), and left ventricular ejection fraction was 46-66% (mean value 57.5%) during 6 months of follow-up.


Discussion

  In the present case series study, 6 consecutive patients with complex coronary artery disease underwent successful PCI under ECMO support without procedural complications and with hemodynamic stability but a 33.3% rate of EMCO site-related complications. Because of the small sample size and single center, retrospective design of the present experience, the effectiveness of ECMO-supported PCI as an alternative to pharmacotherapy only in patients who are not suitable candidates or refuse to undergo surgical intervention deserves further study to inform strict indications for its use. ECMO might be more beneficial for patients in critical condition with a high mortality risk. Because ECMO is expensive, cost and risk-benefit analyses are need. Although in theory ECMO duration appears unlimited, the rates of complications such as bleeding, thrombus, infection, hepatic and renal injury and distal limb ischemic necrosis increase with ECMO duration [12-14]. The ECMO site-related complicated complications in 2 of the 6 patients studied here stress the need, as circulatory function recovery allows, for earlier rather than later ECMO weaning along with close monitoring.


References:

   1He, W. M., Li, C. L., Sun, Y., Zhou, Z. and Mai, Y. F.: Safety and efficacy of a novel technique in the use of fractional flow reserve in complex coronary artery lesions. Chin Med J (Engl). 2015;128:822-825

   2Sharma, D., Kotowycz, M. A., Sharma, V., Choudhury, A., Chan, W., Freixa, X., Dzavik, V. and Overgaard, C. B.: Characteristics and outcomes of patients undergoing percutaneous coronary intervention within 1 year of coronary artery bypass graft surgery. Catheter Cardiovasc Interv. 2017;90:186-193

   3Naqvi, S. Y., Klein, J., Saha, T., McCormick, D. J. and Goldberg, S.: Comparison of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Disease. AM J CARDIOL. 2017;119:520-527

 4Kulik, A.: Quality of life after coronary artery bypass graft surgery versus percutaneous coronary intervention: what do the trials tell us? CURR OPIN CARDIOL. 2017;32:707-714

   5Ternus, B. W., Jentzer, J. C., El, S. A., Eleid, M. F., Bell, M. R., Murphy, J. G., Rihal, C. S. and Barsness, G. W.: Percutaneous Mechanical Circulatory Support for Cardiac Disease: Temporal Trends  in Use and Complications Between 2009 and 2015. J INVASIVE CARDIOL. 2017;29:309-313

   6Thomaz, P. G., Moura, L. J., Muramoto, G. and Assad, R. S.: Intra-aortic balloon pump in cardiogenic shock: state of the art. Rev Col Bras Cir. 2017;44:102-106

   7Weems, M. F., Friedlich, P. S., Nelson, L. P., Rake, A. J., Klee, L., Stein, J. E. and Stavroudis, T. A.: The Role of Extracorporeal Membrane Oxygenation Simulation Training at Extracorporeal Life Support O rganization Centers in the United States. SIMUL HEALTHC. 2017;12:233-239

   8Gutsche, J., Vernick, W. and Miano, T. A.: One-Year Experience With a Mobile Extracorporeal Life Support Service. ANN THO RAC SURG. 2017;104:1509-1515

   9Touchan, J. and Guglin, M.: Temporary Mechanical Circulatory Support for Cardiogenic Shock. Curr Treat Options Cardiovasc Med. 2017;19:77

  10Liu, S., Ravandi, A., Kass, M. and Elbarouni, B.: A Case Of Awake Percutaneous Extracorporeal Membrane Oxygenation For High-risk Percutaneous Coronary Intervention. Cureus. 2017;9:e1191

  11Chung, S. Y., Tong, M. S., Sheu, J. J., Lee, F. Y., Sung, P. H., Chen, C. J., Yang, C. H., Wu, C. J. and Yip, H. K.: Short-term and long-term prognostic outcomes of patients with ST-segment elevation myocardial infarction complicated by profound cardiogenic shock undergoing early extracorporeal membrane oxygenator-assisted primary percutaneous coronary intervention. INT J CARDIOL. 2016;223:412-417

  12Thomas, J., Kostousov, V. and Teruya, J.: Bleeding a  n dThrombotic Complications in the Use of Extracorporeal Membrane Oxygenation. SEMIN THROMB HEMOST. 2018;44:20-29

  13Lamb, K. M. and Hirose, H.: Vascular Complications in Extracoporeal Membrane Oxygenation. CRIT CARE CLIN. 2017;33:813-824

  14Liao, X., Li, B. and Cheng, Z.: Extracorporeal membrane oxygenation in adult patients with acute fulminant myocarditis : Clinical outcomes and risk factor analysis. HERZ. 2017;

 

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郑金刚
单位:中日友好医院(中日医院)
简介:  医学博士,主任医师,博士生导师,中日医院心脏科主任   美国冠脉介入协会专家组成员(FSCAI
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