Extracorporeal life support during and after bilateral sequential lung transplantation in patients with pulmonary artery hypertension

Abstract

The use of extracorporeal membrane oxygenator instead of standard cardiopulmonary bypass during lung transplantation is debatable. Moreover, recently, the concept of prolonged postoperative extracorporeal membrane oxygenator (ECMO) support has been introduced in many transplant centers to prevent primary graft dysfunction (PGD) and improve early and long-term results.The objective of this study was to review the results of our extracorporeal life support strategy during and after bilateral sequential lung transplantation (BSLT) for pulmonary artery hypertension. We review retrospectively our experience in BSLT A total of 38 patients were identified. Nine patients were transplanted using cardiopulmonary bypass (CPB), in eight cases CPB was followed by a prolonged ECMO (pECMO) support, 14 patients were transplanted on central ECMO support, and seven patients were transplanted with central ECMO support followed by a pECMO assistance. The effects of different support strategies were evaluated, in particular in-hospital morbidity, mortality, incidence of PGD, and long-term follow-up. The use of CPB was associated with poor postoperative results and worse long-term survival compared with ECMO-supported patients. Predictive preoperative factors for the need of intraoperative CPB instead of ECMO were identified. The pECMO strategy had a favorable effect to mitigate postoperative morbidity and mortality, not only in intraoperative ECMO-supported patients, but even in CPB-supported cases. In our experience, ECMO may be considered as the first choice circulatory support for lung transplantation. Sometimes, in very complex cases, CBP is still necessary. The pECMO strategy is very effective to reduce incidence of PGD even in CPB-supported patients. K E Y W O R D S cardiopulmonary bypass, extracorporeal membrane oxygenation, extracorporeal support technique, lung transplantation, pulmonary hypertension 630 | DELL'AMORE Et AL. F I G U R E 1 Examples of clear indication for CPB instead of ECMO. A, extreme cardiomegaly. B, severe dilatation of the right and left pulmonary artery branches. C, severe aneurysm of the main pulmonary artery. D, over-systemic pulmonary artery hypertension (pulmonary artery pressure shown in yellow and systemic pressure shown in red) [Color figure can be viewed at wiley onlin elibr ary.com] F I G U R E 2 ECLS techniques. A, aorto-bicaval CPB cannulation. B, aorto-bicaval CPB cannulation with pulmonary artery vent (black arrow). C, central aorto-right atrium ECMO cannulation. D, prolonged ECMO setting with peripheral femoro-femoral cannulation with distal leg perfusion [Color figure can be viewed at wiley onlin elibr ary.com] How to cite this article: Dell'Amore A, Campisi A, Congiu S, et al. Extracorporeal life support during and after bilateral sequential lung transplantation in patients with pulmonary artery hypertension.

Factors associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation

“…It might probably due to excessive bleeding and transfusion requirements and prolonged ischemic time during transplantation. Finally, other groups have recently reported on the use of ECMO support profilactically in lung transplantation showed an improve survival, which could demonstrate the benefit of prophylactic ECMO [25,26]. However, in our center ECMO was usually only reserved for complex transplantation or to support intraoperative unstable patients, which may also influence the outcome.…”

Extracorporeal membrane oxygenation in lung transplantation: Indications, techniques and results

“…Indications for intra-operative ECMO include a combination of the following conditions[ 4 ]: (1) Hypercapnia; (2) Low arterial saturation (< 90%); (3) Low cardiac index (< 2 L/min/m 2 ); and (4) Significant increase in pulmonary pressure. Between 2017 and 2020, five studies reported detailed outcomes on the use of ECMO during LTx (Table 3 )[ 41 , 43 - 46 ] . Central (c) ECMO is commonly used in the intra-operative setting.…”

Extracorporeal membrane oxygenation and lung transplantation

“…Dell'Amore et al [71] reported in 2020 their analysis of 38 patients who underwent LT and who had peripheral VA ECMO as a planned prolongation of ECMO into the postoperative period. They described lower incidence of PGD and improved survival in the postoperatively ECMO supported patients.…”

“…They described lower incidence of PGD and improved survival in the postoperatively ECMO supported patients. Table 6 lists case series of patients with planned postoperatively extended intraoperative ECMO [59,[68][69][70][71].…”