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OBJECTIVESLung transplantation for idiopathic pulmonary arterial hypertension has the highest reported postoperative mortality of all indications. Reasons lie in the complexity of treatment of these patients and the frequent occurrence of postoperative left ventricular failure. Transplantation on intraoperative extracorporeal membrane oxygenation support instead of cardiopulmonary bypass and even more the prolongation of extracorporeal membrane oxygenation into the postoperative period helps to overcome these problems. We reviewed our experience with this concept.METHODSAll patients undergoing bilateral lung transplantation for idiopathic pulmonary arterial hypertension on intraoperative extracorporeal membrane oxygenation with or without prophylactic extracorporeal membrane oxygenation prolongation into the postoperative period between January 2000 and December 2014 were retrospectively analysed.RESULTSForty-one patients entered the study. Venoarterial extracorporeal membrane oxygenation support was prolonged into the postoperative period for a median of 2.5 days (range 1–40). Ninety-day, 1-, 3- and 5-year survival rates for the patient collective were 92.7%, 90.2%, 87.4% and 87.4%, respectively. When compared with 31 patients with idiopathic pulmonary arterial hypertension transplanted in the same period of time without prolongation of extracorporeal membrane oxygenation into the postoperative period, the results compared favourably (83.9%, 77.4%, 77.4%, and 77.4%; P = 0.189). Furthermore, these results are among the best results ever reported for this particularly difficult patient population.CONCLUSIONSBilateral lung transplantation for idiopathic pulmonary arterial hypertension with intraoperative venoarterial extracorporeal membrane oxygenation support seems to provide superior outcome compared with the results reported about the use of cardiopulmonary bypass. Prophylactic prolongation of venoarterial extracorporeal membrane oxygenation into the early postoperative period provides stable postoperative conditions and seems to further improve the results.

Objectives: Extracorporeal life support is increasingly used to bridge deteriorating candidates to lung transplantation. Nevertheless, only few systematic reports with a limited number of patients exist describing this practice and its changes over time. Methods:We retrospectively reviewed our institutional database and performed an era analysis to identify trends over time and risk factors for mortality. After applying propensity score matching, outcomes of bridged patients were compared with those of standard lung transplantation recipients.Results: Extracorporeal life support was used in 120 patients as an intention to bridge to lung transplantation. Eleven patients (9.2%) were bridged between 1998 and 2004, 39 patients (32.5%) were bridged between 2005 and 2010, and 70 patients were bridged (58.3%) between 2010 and 2017. In the first era, the main bridging modality was venoarterial-extracorporeal membrane oxygenation (n ¼ 10, 90.9%), whereas venovenous devices were primarily used in later eras (second era: n ¼ 18, 46.2%; third era: n ¼ 39, 55.8%). In the second and third eras, 9 patients (23.1%) and 24 patients (34.3%) could be bridged awake. Short-term outcome was poor in the first era, with only 36.4% of patients discharged alive but improved in later eras (53.8% and 77.1%; P ¼ .002). Extracorporeal life support-bridged patients showed an impaired short-term outcome compared with standard recipients. However, survival conditional on 90 days did not differ among the groups (P ¼ .178). In univariate and multivariate analyses, awake extracorporeal life support was protective for survival, whereas acute retransplantation was a risk factor for mortality.Conclusions: Over the past 2 decades, the role of extracorporeal life support bridging evolved from an acute rescue therapy to a semi-elective procedure. Stratified outcome analysis revealed that extracorporeal life support bridging yielded similar long-term survival compared with nonbridged patients.

Plasma disappearance rate of indocyanine green (PDRICG) has been proposed for assessment of liver function in liver transplants donors and recipients, in patients with chronic liver failure, and as a prognostic factor in critically ill patients. The assessment of PDRICG using a newly developed noninvasive digital pulse densitometry method was simultaneously compared to invasive aortic fiber-optic method in patients undergoing orthotopic liver transplantation (OLT). Fourteen consecutive liver transplant candidates (11 male, 3 female) were prospectively enrolled into the study. A 4F aortic catheter with an integrated fiber-optic device and a thermistor was inserted via a femoral artery sheath for invasive aortic (INV) PDRICG assessment in all patients. The fiber-optic device was connected to a computer system (COLD-Z021, PULSION Medical Systems, Munich, Germany). A finger-piece sensor was used for non-invasive (NINV) pulsedensitometric PDRICG assessment. For the PDRICG assessment .5 mg/kg of ICG in cooled saline (10-15 mL) was injected through a central venous catheter. The assessments of PDRICG were performed after induction of anesthesia, after clamping of the hepatic artery, after clamping of the inferior vena cava, after reperfusion of the graft, and on the first postoperative day. During the PDRICG measurements, the investigators were blinded for the results of the noninvasive monitoring. Seventy-one pairs of measurements were performed successfully. PDRICG ranged from 0%/min to 43.8 %/min (11.6%/ min ؎ 9.6 %/min, mean ؎ SD) for invasive and from I ndocyanine green (ICG) is a water-soluble anioniccompound that is injected intravenously and binds mainly albumin and ␤-lipoproteins in the plasma. ICG is then selectively taken up by hepatocytes, independent of adenosine triphosphate (ATP), and is later excreted unchanged into the bile via an ATP-dependent transport system. It is not metabolized and does not undergo enterohepatic recirculation. 1 Due to these features, ICG has been proposed for assessment of liver function in liver tranplants donors and recipients, in patients with chronic liver failure, and as a prognostic factor in critically ill patients. 2 -5 Plasma disappearance rate of ICG (PDRICG), plasma clearance rate, and retention rate are some of the parameters calculated from the decay of the dilution curve after intravenous ICG injection. PDRICG is the most commonly used ICG-derived parameter for clinical and experimental assessment of liver function with normal range of 18 -25 %/min.There are different techniques assessing the PDRICG in vivo. The gold standard relies on serial blood sampling after ICG injection at certain time intervals and consecutive spectrophotometric concentration analysis. 3,4 However, this method proves to be both expensive and time consuming. Another method implements the use of a fiber-optic aortic catheter inserted via the femoral artery sheath. 6,7 This method was found to correlate well with the serial blood-samAbbreviations: ICG, indocyanine green; ATP, adenosine tripho...

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