Venovenous extracorporeal life support after pulmonary endarterectomy: indications, techniques, and outcomes.
BACKGROUND
Pulmonary endarterectomy is the accepted therapy for thromboembolic pulmonary hypertension. A recognized complication of this surgery is the postoperative development of reperfusion edema, a potentially fatal cause of respiratory failure. Because reperfusion edema can be a reversible process, temporizing support measures may be life saving.


METHODS
We retrospectively reviewed our experience with venovenous extracorporeal life support (V-V ECLS) from July 1990 to February 2006, in 20 adult patients (mean age 50.5 +/- 14.5 years) presenting with potentially reversible respiratory failure after pulmonary endarterectomy. This subset of patients comprised 1.12% of our total pulmonary endarterectomy experience during that time (1,790 cases).


RESULTS
Overall in-hospital survival was 30.0% for patients requiring ECLS support after pulmonary endarterectomy versus 94.2% for patients who underwent pulmonary endarterectomy alone during the same timeframe. V-V ECLS was instituted at a mean of 86.8 hours after surgery. The mean duration of V-V ECLS was 123.4 +/- 71.3 hours. The most common cause of death in ECLS patients after pulmonary endarterectomy was pulmonary hemorrhage. Survival was greater in patients cannulated within 120 hours of surgery (46.2% survival; 6 of 13 patients) compared with those cannulated after 120 hours (0 of 7 patients). Multiple logistic regression identified long duration of mechanical ventilation pre-ECLS and severity of preoperative pulmonary hypertension together as predictors of mortality.


CONCLUSIONS
A small subset of patients undergoing pulmonary endarterectomy develop temporary life-threatening respiratory failure secondary to severe reperfusion edema. In those patients with satisfactory hemodynamic outcome, V-V ECLS is a therapeutic option when all other conventional strategies have been exhausted.
Thistlethwaite
Patricia A
PA
Division of Cardiothoracic Surgery, University of California, San Diego, San Diego, California 92103-8892, USA. pthistlethwaite@ucsd.edu
Madani
Michael M
MM
Kemp
Aaron D
AD
Hartley
Mary
M
Auger
William R
WR
Jamieson
Stuart W
SW
D000328:Adult; D000368:Aged; D004691:Endarterectomy / Q000009:adverse effects*; D005112:Extracorporeal Circulation / Q000379:methods*; D005260:Female; D006801:Humans; D006976:Hypertension, Pulmonary / Q000209:etiology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011651:Pulmonary Artery / Q000601:surgery*; D011654:Pulmonary Edema / Q000209:etiology / Q000628:therapy*; D011655:Pulmonary Embolism / Q000150:complications / Q000601:surgery*; D015427:Reperfusion Injury / Q000209:etiology / Q000628:therapy; D012189:Retrospective Studies; D016896:Treatment Outcome