Thoracic surgery in adult patients receiving extracorporeal membrane oxygenation: A 16-year experience

Abstract

Objectives: Patients on ECMO are at risk from thoracic complications such as bleeding or pneumothorax, which may subsequently necessitate thoracic surgical intervention. Methods: We reviewed a prospective database of 550 adults put on ECMO between 1995 and 2011. We aimed to 1) analyse the indication and nature of thoracic surgical intervention in these patients and 2) to analyse the effect of a change in ECMO circuit from roller pump to centrifugal pump on transfusion requirements pre and post-thoracotomy. Results: Forty thoracotomies were performed in 18 patients [61% male, age 31 (14 - 56) years, one bilateral procedure]. The indications for ECMO included: pneumonia 14/18 (78%), trauma 2/18 (11%), and other 2/18 (11%). ECMO was continued in total for 13 (1 - 257) days and first thoracotomy was required after 10 (1 - 183) days. The indications for thoracotomy were: 11/19 (58%) excessive bleeding post chest drain insertion 11/19 (58%); uncontrolled air leak (9/19, 47%) and pleural effusion (4/19, 21%). The primary operations were 12/19 (63%) evacuation of haemothorax, 3/19 (16%) lung repair, 2/19 (11%) diagnostic lung biopsy, and other 2/19 (11%). Ten patients needed a further 21 thoracotomies (3 lobectomies); 2 (1 - 5) per patient. In total, 30/40 (75%) thoracotomies were performed for bleeding complication. The change from roller to centrifugal pump reduced post-op transfusion requirements in these patients (roller: 11.5 [0 - 63] vs centrifugal: 4 [0 - 29], P=0.14). The in-hospital mortality was 7/18 (39%) patients. Poor prognostic indicators included: dialysis (10/18, P<0.01), intestinal bleeding or ischaemia (3/18, P=0.04). Conclusions: The need for thoracotomy whilst on ECMO is 3.3% in this large series. Intervention may be complicated thus either ECMO specialists should have thoracic training or thoracic surgeons should be on-site. Potential mortality is high and coagulopathy and the type of circuit predispose to excessive transfusion requirements in this group of patients.