Intraoperative support during lung transplantation

Abstract

The role of intraoperative mechanical support during lung transplantation (LTx) is essential to provide a safe hemodynamic and ventilatory status during critical intraoperative events. This hemodynamic and ventilatory stability is vital to minimize the odds of suboptimal outcomes, especially considering that, due to the scarcity of donors and the fact that more and more patients with significant comorbidities are being considered for this therapy, a more aggressive approach is often needed by the transplant centers.Hence, the attenuation of any potential injury that can happen during this complex event is paramount.While a thorough assessment of the donor and optimization of postoperative care is pursued, certainly protective intraoperative management would also contribute to better outcomes. Understanding each patient's underlying anatomy and cardiopulmonary physiology, associated with awareness of critical events during a complicated procedure like LTx, is essential for a precise indication and safe use of support.Cardiopulmonary bypass (CPB) and veno-arterial extracorporeal membrane oxygenation (VA ECMO) have been the most common approaches used, with the latter gaining popularity more recently and we have used VA ECMO exclusively for the last decade. New technologies certainly contributed to more liberal use of VA ECMO intraoperatively, enabling a protecting and physiologic environment for the newly implanted grafts.In this setting, potential prophylactic use for lung protection during a critical period is also considered.

Donor and recipient risk factors for the development of primary graft dysfunction following lung transplantation

“…Common indications include pre-operative MCS use warranting continued use in the operative setting, hemodynamic instability immediately before transplantation, or a high risk of decompensation upon induction of anesthesia. Additionally, patients that have refractory hypoxia during transplantation (most notably after implantation of the first graft), refractory pulmonary hypertension >50mmHg (typically just before implantation, examined via occlusion of the pulmonary artery), and hemorrhage may also result in acute necessity for MCS ( 106 ). Historically, cardiopulmonary bypass (CPB) has been the method of choice used for this purpose.…”

“…Venoarterial Extracorporeal Membrane Oxidation (VA-ECMO) has continued to gain popularity as an alternative method of MCS and is now widely used for perioperative hemodynamic support around the time of LTx ( 106 , 110 – 112 ). In addition, benefits of ECMO over CPB include avoidance of full heparinization which reduces the risk of hemorrhagic complications, the ability to extend ECMO into the ICU for continued circulatory support if needed, and reduction of trauma to the allograft to allow for controlled reperfusion and lung parenchyma-protecting ventilation strategies.…”

Intraoperative Extracorporeal Support during Lung Transplantation: Not Just for the High-Risk Patient

“…Historically, intraoperative support was used primarily to provide complete control of hemodynamics and ventilatory status, especially in high-risk patients [ 35 , 36 ]. However, there has been a recent move towards creating a protective environment for the graft [ 37 ], especially during early reperfusion.…”

“…Ischemia-reperfusion injury results from endothelial and epithelial injury releasing cytokines and triggering innate immune response, leading to a rapid inflammatory effect [ 38 ]. This clinically manifests as early graft dysfunction and non-cardiogenic pulmonary edema [ 36 , 39 ]. The injury and disruption to the endothelial barrier and subsequent inflammation are mediated by oxidative injury from reactive oxygen species created as a response to ischemia [ 38 ].…”