Extra Corporeal Membrane Oxygenation (ECMO) during thoracic procedures excluding lung transplantation. A multicentre study. RINIERI Philippe

1. Extra Corporeal Membrane Oxygenation (ECMO) during thoracic
procedures excluding lung transplantation. A multicentre study.
RINIERI Philippe1, PEILLON Christophe1, BESSOU Jean-Paul2, VEBER Benoît3,
FALCOZ Pierre-Emmanuel4, LITZLER Pierre-Yves2, BASTE Jean-Marc1
1Service de chirurgie thoracique du Pr Peillon, CHU Charles Nicolle, 1 rue de Germont 76031 Rouen
2Service de chirurgie thoracique et cardio-vasculaire du Pr Bessou, CHU Charles Nicolle, 1 rue de Germont 76031 Rouen
3Service de réanimation chirurgicale du Pr Veber, CHU Charles Nicolle, 1 rue de Germont 76031 Rouen
4Service de chirurgie thoracique du Pr Wihlm, Hôpitaux universitaires de Strasbourg-Nouvel Hôpital Civil, 1 place de l’Hôpital 67091 Strasbourg
Preoperative CT scan: Tracheal wound,
p n e u m o m e d i a s t i n u m , s u b c u t a n e o u s
emphysema. Veno-venous ECMO for total
respiratory support during tracheal repair.
Objective: ECMO for respiratory support is increasingly used
in intensive care units (ICU), but rarely used during thoracic
surgical procedures outside the transplantation setting. ECMO
is an alternative to conventional cardiopulmonary bypass for
major tracheal and bronchial surgery without in-field ventilation.
Our aim is to describe its benefits, indications and
complications.
Patients and Methods: Multicentre retrospective study
(questionnaire) of ECMO use during thoracic surgical
procedure excluding lung transplantation.
Results: From March 2009 to September 2012, 17 of the 33
centres in France applied ECMO within these indications in 36
patients. They were veno-venous (n=20) or veno-arterial
(n=16). Ten veno-arterial ECMO were performed with
peripheral cannulation and six with central cannulation; all
veno-venous ECMO were achieved through peripheral
cannulation. Total respiratory support (Group 1): 28 without
mechanical ventilation (23 tracheo-bronchial procedures, 5
single lung procedures). Partial respiratory support (Group 2):
Five patients with respiratory insufficiency. Surgery in the
setting of ARDS with pre-operative ECMO (Group 3): Three
patients. Mortality at 30 days in groups 1, 2 and 3 was 7, 40
and 67% respectively (p<0.05). In group 1, ECMO was weaned
intraoperatively or within 24h in 75% . In group 2, ECMO was
weaned in ICU over several days. In group 1, two patients with
veno-arterial support were converted to veno-venous for
chronic respiratory support. Bleeding was the major
complication with 17% of the patients requiring return to
theatre for haemostasis. There were two cannulation related
complications (6%).
Conclusion : Veno-venous or veno-arterial ECMO is a
satisfactory alternative to in-field ventilation in complex
tracheo-bronchial surgery or in single lung surgery.
ECMO needs to be considered and used in precarious
post-operative respiratory condition. Full respiratory
support can be achieved with veno-venous ECMO.
Indications and results of ECMO during surgery in
patients with ARDS needs further careful investigation.
veno-venous
ECMO Dual-lumen cannula into the
internal jugular vein
Femoro-jugularIsolated respiratory support
(sufficient and less invasive)
Central cannulation
Peripheral cannulation
veno-arterial
ECMO
Circulatory support potentially necessary
(risk of cardiac failure or vascular wound)
Complex
Tracheo-
bronchial or
single lung
surgery
emergency
sternotomy
Anterograde
perfusion
Femoro-femoral
Femoro-axillary
Figure 3: Use of ECMO, as total respiratory support in thoracic surgery, except transplantation
Types of ECMO
(cannulation)
Veno-venous Veno-arterial
(peripheral)
Veno-arterial
(central)
Total
Trachea 5 3 2 10
Carena 5 2 4 11
Left bronchial stump 0 2 0 2
Single lung 2 3 0 5
Pulmonary resection
isolated
6 0 0 6
Others (thoracic
trauma, pneumothorax)
2 0 0 2
Total 20 10 6 36
Table 1: Types of ECMO by operating indication
Preoperative CT scan: Left bronchoesophageal
fistula after concomittant radio-chemotherapy for
oesophagus carcinoma. Veno-arterial ECMO for
total respiratory support during bronchus repair.
Figure 2: Overall survival: group 1 (total respiratory support), group 2 (partial respiratory support),
group 3 (preoperative ECMO for ARDS)
Figure 1: Overall survival
group A (scheduled patients)
group B (emergency)
Scheduled patients (27)
Emergency (9)
p=0,117
1
2
3
A
B