分析体外膜肺氧合(ECMO)在肺移植围手术期应用的有效性。

回顾性分析在无锡市人民医院肺移植中心行肺移植且围手术期应用ECMO的受者临床资料。选取2015年1月至2019年12月在本院肺移植中心行肺移植且围手术期应用ECMO的390例肺移植受者作为研究对象。根据ECMO置管方式不同将受者分为V-A组(n＝244例)和V-V组(n＝146例)；根据受者术后ECMO支持时间是否>72 h将术后应用ECMO受者分为未延长组(≤72 h)和延长组(>72 h)，并将延长组受者根据ECMO置管方式分为V-A延长组和V-V延长组。收集受者性别、年龄、原发病、手术方式(双肺或单肺)、ECMO上机时间点、ECMO置管方式(V-A或V-V)、围手术期ECMO支持时间及撤除情况等临床资料。组间符合正态分布计量资料比较采用独立样本t检验，非正态分布计量资料比较采用Mann-Whitney U检验，计数资料比较采用卡方检验或Fisher确切概率法。采用Kaplan-Meier法绘制术后应用ECMO的肺移植受者90 d生存曲线，累积生存率比较采用log-rank检验。P<0.05为差异有统计学意义。

390例受者肺移植手术年份分布：2015至2019年分别为32、77、87、97和97例。V-A组和V-V组受者原发病中特发性肺动脉高压例数分别为20和0例，差异有统计学意义(χ²＝12.614，P<0.05)，其余一般资料差异均无统计学意义(P均>0.05)。剔除V-A组和V-V组特发性肺动脉高压受者后，ECMO成功撤除的比例分别为211/224和137/146，差异无统计学意义(χ²＝0.021，P>0.05)。390例围手术期应用ECMO受者中术后应用ECMO支持274例，其中未延长组230例，延长组44例。未延长组受者术后30、60和90 d累积生存率分别为90.9%、86.5%和77.4%，均显著高于延长组(75.0%、70.5%和59.1%)，差异有统计学意义(χ²＝7.840，P<0.05)。延长组受者中V-A延长组26例，V-V延长组18例，两组受者术后30、60和90 d累积生存率差异无统计学意义(χ²＝0.654，P>0.05)。

ECMO在肺移植受者围手术期发挥重要作用；V-V置管方式创伤小，更适合无严重心室功能障碍者，特发性肺动脉高压患者宜选择V-A置管方式；术后ECMO支持时间延长较不延长受者预后差。

To evaluate the effect of extracorporeal membrane oxygenation (ECMO) in the perioperative period of lung transplantation.

The clinical data of patients transplanted in the Lung Transplantation Center of Wuxi People′s Hospital with perioperative application of ECMO were analyzed retrospectively. A total of 390 lung transplant recipients receiving ECMO during the perioperative phase from January 2015 to December 2019 were selected as subjects. The 390 recipients were divided into V-A group (n=244 ) and V-V group (n=146), and the postoperative applied ECMO recipients were grouped into unextended group (≤72 h) and extended group (>72 h) based on whether the postoperative ECMO support time was >72 h, and recipients in extended group (>72 h) were divided into V-A extended group and V-V extended group. Clinical data were collected such as sex, age, primary disease, mode of surgery (double or single lung), ECMO start time, ECMO support mode (V-A or V-V), peroperative ECMO support time, and withdrawal. Groups meeting normal distribution measurements were compared using the independent sample t test. Non-normal distribution measurement data between groups were compared using Mann-Whitney U test. Count data between groups were compared using the chi-square test or Fisher exact probability method. The 90 d survival curves of lung transplant recipients supported by ECMO were estimated using Kaplan-Meier method, and cumulative survival comparisons were performed using log-rank test. A P value less than 0.05 was considered statistically significant.

Year distribution of 390 recipients: 32 in 2015, 77 in 2016, 87 in 2017, 97 in 2018, and 97 in 2019. Statistically significant difference was found in the proportion of idiopathic pulmonary hypertension in the primary disease of recipients in the V-A group and V-V group (χ²=12.614, P<0.05), and none of the remaining general data were statistically significant (all P>0.05). When the recipients with idiopathic pulmonary arterial hypertention were removed, the removal rates of ECMO of V-A group and V-V group were 211/224 and 137/146, and there was no statistically significant (χ²=0.021, P>0.05). There were 274 patients in 390 perioperative ECMO recipients received post-operative ECMO support, including 230 in the unextended group and 44 in the extended group. The cumulative survival rates of 30 d, 60 d, and 90 d in the unextended group were 90.9%, 86.5%, and 77.4%, respectively, all significantly higher than the extended group (75.0%, 70.5%, and 59.1%) and were statistically significant (χ²=7.840, P<0.05) . The extended group was divided into 26 in the V-A extended group and 18 in the V-V extended group, with no statistically significant difference in cumulative survival at 30 d, 60 d and 90 d between the two groups (χ²=0.654, P>0.05).

ECMO plays an important role in the perioperative period of lung transplantation. V-V catheterization is performed with small trauma, and V-V ECMO mode is more suitable for patients without severe ventricular dysfunction. Patients with idiopathic pulmonary hypertension should choose V-A ECMO mode. Patients with extended postoperative ECMO support time had worse prognosis than unextended patients.