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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.
2018/11/23 9:35:23    

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


  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.


  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.


  2.1Study 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%,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.  


  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.


  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.


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