COUNTERPOINT: Should Patients With Advanced Lung Disease Be Offered Extracorporeal Membrane Oxygenation as a Bridge to Transplant If They Have Not Yet Been Listed for Lung Transplant? No

Warren, Whittney; Walter, Robert; Mason, Phillip E.

doi:10.1016/j.chest.2020.02.004

Cited by 6 publications

(4 citation statements)

References 9 publications

(10 reference statements)

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“…However, for those with end-stage cardiopulmonary disease who are excluded to receive ECMO based on certain criteria, death is certain. Issues related to the availability of resources, distribution of donor organs, and ethical concerns need broader discussion ( 17 , 18 ).…”

Section: Discussionmentioning

confidence: 99%

Expanded extracorporeal membrane oxygenation bridge to heart and lung transplant candidate selection does not impact outcomes compared to traditional candidate selection criteria

Wahab¹,

Hanson²,

Peters³

et al. 2023

J Thorac Dis

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Extracorporeal membrane oxygenation is used as a bridge to transplant (ECMO-BTT) in selected patients. The objective of this study was to determine whether 1-year post-transplant and post-ECMO survival are impacted by traditional compared to expanded selection criteria. We performed a retrospective study of patients >17 years who received ECMO as bridge to transplant (BTT) or bridge to transplant decision for lung or combined heart and lung transplantation at the Mayo Clinic Florida and Rochester. Institutional protocol excludes patients >55 years, maintained on steroids, unable to participate in physical therapy, with body mass index >30 or <18.5 kg/m 2 , non-pulmonary end-organ dysfunction, or unmanageable infections from ECMO-BTT. For this study, adherence to this protocol was considered traditional whereas exceptions to the protocol were considered expanded selection criteria. A total of 45 patients received ECMO as bridge therapy. Out of those 29 patients (64%) received ECMO as bridge to transplant and 16 patients (36%) as bridge to transplant decision. The traditional criteria cohort consisted of 15 (33%) patients and expanded criteria cohort consisted of 30 (67%) patients. In the traditional cohort, 9 (60%) of 15 patients were successfully transplanted compared to 16 (53%) of 30 patients in the expanded criteria cohort. No difference in being delisted or dying on the waitlist (OR: 0.58, CI: 0.13–2.58), surviving to 1-year post-transplant (OR: 0.53, CI: 0.03–9.71) or 1-year post-ECMO (OR: 0.77, CI: 0.0.23–2.56) was observed between the traditional criteria and expanded criteria cohorts. At our institution, we did not see differences in odds of 1-year post-transplant and post-ECMO survival between those who met traditional criteria compared to those who did not. Multicenter, prospective studies are needed to evaluate the impact of ECMO-BTT selection criteria.

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Section: Discussionmentioning

confidence: 99%

Expanded extracorporeal membrane oxygenation bridge to heart and lung transplant candidate selection does not impact outcomes compared to traditional candidate selection criteria

Wahab¹,

Hanson²,

Peters³

et al. 2023

J Thorac Dis

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“…60,61 Furthermore, there is some debate about whether patients without a clear contraindication who are not yet listed for lung transplant should be offered ECMO in the presence of physiologic deterioration. 16,17 ECMO may be cautiously considered for patients not yet listed for lung transplant. 62 In this context, ECMO is generally considered a "bridge to decision," where the decision whether to list a patient has not yet been made.…”

Section: Patient Selection and Timing Of Initiationmentioning

confidence: 99%

“…Approaches to patient selection and timing for pretransplant ECMO initiation are inconsistent. 16,17 Choice of mode and configuration to meet the physiologic deficit posed by different ESLD pathologies varies across transplant centers. 9,[18][19][20] The indications to withhold transplant from patients receiving ECMO-BTLT are unclear.…”

mentioning

confidence: 99%

Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant

Stokes

Gannon

Bacchetta

2021

Semin Respir Crit Care Med

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Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary technology capable of supporting cardiac and respiratory function in the presence of end-stage lung disease. Initial experiences using ECMO as a bridge to lung transplant (ECMO-BTLT) were characterized by high rates of ECMO-associated complications and poor posttransplant outcomes. More recently, ECMO-BTLT has garnered success in preserving patients' physiologic condition and candidacy prior to lung transplant due to technological advances and improved management. Despite recent growth, clinical practice surrounding use of ECMO-BTLT remains variable, with little data to inform optimal patient selection and management. Although many questions remain, the use of ECMO-BTLT has shown promising outcomes suggesting that ECMO-BTLT can be an effective strategy to ensure that complex and rapidly decompensating patients with end-stage lung disease can be safely transplanted with good outcomes. Further studies are needed to refine and inform practice patterns, management, and lung allocation in this high-risk and fragile patient population.

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“…However, expert ECMO and transplant centers are not common, and less than 25% have the volume to support equivocal outcomes with BTT on ECMO. 6 Most programs should not use ECMO for BTTE, because most centers should not use ECMO for BTT. In addition, transport is equally problematic.…”

mentioning

confidence: 99%