The feasibility of venovenous extracorporeal life support to treat acute respiratory failure in adult cancer patients.

Venovenous extracorporeal life support (VV-ECLS) is a lifesaving but invasive treatment for acute respiratory failure (ARF) that is not improved with conventional therapy. However, using VV-ECLS to treat ARF in adult cancer patients is controversial. This retrospective study included 14 cancer patients (median age: 58 years [interquartile range: 51-66]; solid malignancies in 13 patients and hematological malignancy in 1 patient) who received VV-ECLS for ARF that developed within 3 months after anticancer therapies. VV-ECLS would be considered in selected patients with a P(a)O2/F(i)O2 ratio ≤70 mmHg under advanced mechanical ventilation. Before ECLS, the medians of intubation day, P(a)O2/F(i)O2 ratio, and Sequential Organ Failure Assessment (SOFA) score were 8 (2-12), 62 mmHg (53-76), and 10 (9-14), respectively. The case numbers of bacteremia, thrombocytopenia (platelet count <50000 cells/µL), and neutropenia (actual neutrophil count <1000 cells/µL) detected before ECLS were 3 (21%), 2 (14%), and 1 (7%), respectively. After 24 hours of ECLS, a significant improvement was seen in P(a)O2/F(i)O2 ratio but not in SOFA score. Six patients experienced major hemorrhages during ECLS. The median ECLS day, ECLS weaning rate, and hospital survival were 11 (7-16), 50% (n = 7), and 29% (n = 4). The development of dialysis-dependent nephropathy predicted death on ECLS (odds ratio: 36; 95% confidence interval: 1.8-718.7; P = 0.01). With a median follow-up of 11 (6-43) months, half of the survivors died of cancer recurrence and the others were in partial remission. The most prominent benefit of VV-ECLS is to improve the arterial oxygenation and rest the lungs. This may increase the chance of recovery from ARF in selected cancer patients.

Pulmonary embolectomy in high-risk acute pulmonary embolism: the effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support.

OBJECTIVES: To investigate the effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support (ECLS) in high-risk acute pulmonary embolism (aPE) treated with pulmonary embolectomy. MATERIALS AND METHODS: This retrospective study included 25 consecutive patients of aPE treated with pulmonary embolectomy in a single institution between June 2005 and July 2012. All patients had high-risk aPE identified by computed tomographic angiography and were not suitable for thrombolytic therapy. High-risk aPE here was defined as aPE with (1) hemodynamic instability, (2) a pulmonary artery obstruction index (PAOI)≥0.5, (3) a diameter ratio of right ventricle-to-left ventricle (RV-to-LV)≥1.0, or (4) right heart thrombi. Once the eligibility was confirmed, a 3-staged therapeutic algorithm was adopted to perform an aggressive preoperative resuscitation, an expeditious pulmonary embolectomy with multidisciplinary postoperative care, and a thorough surveillance for recurrence. RESULTS: Among the 25 patients, 24 had a PAOI≥0.5 and 23 had a RV-to-LV diameter ratio≥1.0. Four patients had right heart thrombi. Sixteen patients developed preoperative instability requiring inotropic and/or mechanical support. Eight in the 16 had a preoperative cardiac arrest (CA) and six of these were bridged to surgery on ECLS. Three in the 6 patients weaned ECLS after surgery and survived to discharge. The overall in-hospital mortality was 20% (n=5). A preoperative CA (Odds ratio [OR]: 16, 95% confidence interval [CI]: 1.4-185.4, p=0.027, c-index: 0.80) and a postoperative requirement of ECLS (OR: 36, 95% CI: 2.1-501.3, p=0.008, c-index: 0.85) was the pre- and postoperative predictor of in-hospital mortality. No late deaths or re-admission for recurrence were found during a median follow-up of 19 months (interquartile range: 8-29). CONCLUSION: Pulmonary embolectomy was an effective intervention of high-risk aPE. However, the occurrence of preoperative CA still carried a high mortality in spite of the assistance of ECLS.

Using extracorporeal membrane oxygenation to rescue acute myocardial infarction with cardiopulmonary collapse: the impact of early coronary revascularization.

OBJECTIVES: To investigate the therapeutic impact of combining extracorporeal membrane oxygenation (ECMO) and early coronary revascularization on acute myocardial infarction (AMI)-induced cardiopulmonary collapse. MATERIALS AND METHODS: This retrospective study included 35 consecutive patients rescued by ECMO for AMI-induced cardiopulmonary collapse in a single institution between June 2003 and December 2011. Coronary revascularization was performed soon after ECMO initiation. Percutaneous coronary intervention (PCI) was the primary revascularization strategy. Coronary artery bypass grafting (CABG) was performed if an unsuitable anatomy or unsatisfactory result of PCI. Comparisons were performed in groups with different revascularization strategies and outcomes. RESULTS: Among the 35 patients, 16 underwent CABG and 1 was bridged to transplant after CABG. Compared to patients receiving PCI only, the CABG group showed similar results in ECMO weaning (58% vs. 69%, p=0.51), hospital discharge (32% vs. 50%, p=0.27), and left ventricular ejection fraction before discharge (45% vs. 49%, p=0.92). Regardless of revascularization strategies, this protocol achieved an ECMO-weaning rate of 63% and a hospital discharge rate of 40%. Dialysis-dependent acute renal failure (OR 5.4, 95% CI: 1.1-27.5) and profound anoxic encephalopathy (OR 5.4, 95% CI: 1.1-27.5) predicted non-weaning of ECMO. Age>60 years (OR 7.3, 95% CI: 1.1-51.0) and profound anoxic encephalopathy (OR 24.6, 95% CI: 2.3-263.0) predicted in-hospital mortality. The major cardiovascular adverse effect (MACE)-free survival was 77% in the first year after discharge. CONCLUSION: Early revascularization on ECMO is practical to preserve myocardial viability and bridge patients collapsing with AMI to recovery.