Perioperative extracorporeal membrane oxygenation support for pulmonary endarterectomy: A 17-year experience from the UK national cohort

Abstract

Pulmonary endarterectomy(PEA) is the guideline recommended treatment for patients with chronic thromboembolic pulmonary hypertension(CTEPH). However, some patients develop severe cardiopulmonary compromise either prior to surgery, intraoperatively or early postoperatively. This may result from advanced CTEPH, reperfusion pulmonary oedema, massive endobronchial bleeding or right ventricular(RV) failure secondary to residual pulmonary hypertension. Conventional cardiorespiratory support is ineffective when these complications are severe. Since 2005 we used extracorporeal membrane oxygenation(ECMO) as a rescue therapy for this group. We review our experience with ECMO support in these patients. Retrospective analysis of patients who received perioperative ECMO for PEA from a single national centre from August 2005 to July 2022. Data was prospectively collected. One hundred and ten patients (4.7%) had extreme cardiorespiratory compromise requiring perioperative ECMO. Nine were established on ECMO before PEA. Of those who received ECMO postoperatively, thirty-nine were for refractory reperfusion lung injury, twenty for RV failure, thirty-one for endobronchial bleeding and the remaining eleven were for 'other' reasons such as cardiopulmonary resuscitation following late tamponade and aspiration pneumonitis. 62 (56.4%) were successfully weaned from ECMO. 57 patients left the hospital alive giving a salvage rate of 51.8%. High BMI was identified as an independent risk factor for worse outcome for patients needing ECMO for reperfusion lung injury(p<0.001). Distal disease(Jamieson Type III) and significant residual pulmonary hypertension were also predictors of mortality on ECMO support. Overall 5 and 10-year survival in patients who were discharged alive following ECMO support was 73.9% (SE: 6.1%) and 58.2% (SE: 9.5%), respectively. Perioperative ECMO support has an appropriate role as rescue therapy for this group. Over 50% survived to hospital discharge. These patients had satisfactory longer-term survival.