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Extracorporeal Membrane Oxygenation Support Improves Survival of Patients with Severe Hantavirus Cardiopulmonary Syndrome
C. A. Dietl*, J. A. Wernly*, M. R. Crowley, S. B. Pett, S. F. Yassin, J. P. Sterling, K. Milligan, R. J. Dragan. University of New Mexico Health Sciences Center, Albuquerque, NM
Background: Severe cardiopulmonary failure secondary to Hantavirus infection treated with maximal conventional medical therapy is associated with extremely poor survival. The purpose of this study is to evaluate the outcome using extracorporeal membrane oxygenation support in a subgroup of patients with Hantavirus cardiopulmonary syndrome who had a predicted mortality of 100%, and the complications associated with this treatment modality and the different cannulation techniques.
Methods: Thirty-eight patients with severe Hantavirus cardiopulmonary syndrome who met previously described criteria for non-survival were supported with extracorporeal membrane oxygenation between April 1994 and June 2006. Twenty-five (65.8%) patients were intubated prior to transfer to our hospital. Before cannulation, 38 (100%) patients were on inotropic agents because of hemodynamic deterioration, and 8 (21%) required external cardiac compressions. Cannulation of the femoral vessels was performed on an emergency basis, using a percutaneous approach in 15 (39.5%) and open technique in 23 (60.5%) patients, including the 8 patients cannulated during cardiac arrest. Additional cannulation of the right internal jugular vein was required in 5 (13.1%) patients to improve venous drainage. Duration of extracorporeal membrane oxygenation support averaged 132 hours (range: 5 to 276 hours).
Results: The overall survival was 60.5% (23 of 38 patients). Six (40%) of the 15 patients cannulated percutaneously, and 9 (39.1%) of 23 patients who had open cannulation died. Six (15.8%) patients who died had hypoxic-ischemic encephalopathy presumably related to cardiac arrest prior to cannulation. All survivors recovered completely and were discharged from the hospital after a mean hospital stay of 20.8 days (range: 10 to 39 days). Before January 2000, 8/16 (50%) patients died, whereas 7/22 (31.8%) patients died since January 2000. Complications from percutaneous cannulation occurred in 4/15 (26.6%) patients: retroperitoneal hematoma in 2/15 (13.3%) and lower extremity ischemia in 2/15 (13.3%) patients, which resolved after insertion of a distal perfusion cannula. Complications from open femoral cannulation occurred in 8/23 (34.8%) patients: severe bleeding occurred in 7/23 (30.4%) patients and 1/23 (4.3%) patient required a leg amputation because of lower extremity ischemia despite insertion of a distal perfusion cannula. Six (50%) of the 12 patients with cannulation complications died: 3/3 (100%) patients with leg ischemia, and 3/7 (42.8%) patients with severe bleeding. In contrast, 9 (34.6%) of the 26 patients without cannulation complications did not survive.
Conclusions: Almost two-thirds of the patients with severe Hantavirus cardiopulmonary syndrome who were supported with extracorporeal membrane oxygenation survived and recovered completely. The complications associated with both types of femoral cannulation may be attributed to the fact that all patients were in shock or in full cardiac arrest, and the procedure had to be done expeditiously. Earlier institution of extracorporeal membrane oxygenation and refinement of cannulation techniques may decrease the complication rates and improve the overall survival.
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