Lung Transplantation for Severe Pulmonary Hypertension—Awake Extracorporeal Membrane Oxygenation for Postoperative Left Ventricular Remodelling

Abstract

Early after BLTx for severe PH, the LV may be unable to handle normalized LV preload. This can be effectively bridged with awake venoarterial ECMO.

Advanced pulmonary arterial hypertension: mechanical support and lung transplantation

“…In the PH setting, considerable improvements in early mortality have been reported by some specialist centres. For example, in a cohort of PH patients receiving a bilateral lung transplant combined with post-operative ECMO in a specialist centre after 2010, post-transplant survival rates at 3 and 12 months were reported to be 100% and 96%, respectively [54]. Similar results were obtained from a recent study of IPAH patients receiving prolonged ECMO after bilateral lung transplantation.…”

“…In PAH patients, lung transplantation leads to normalisation of pulmonary vascular resistance, an immediate increase in cardiac output, and an increase in left ventricular filling. This can lead to left ventricular failure, as the left ventricle may not be able to accommodate a normal or high cardiac output in the immediate post-operative period [54,55]. The scale of this complication was demonstrated in a retrospective single-centre study, where almost a third of PAH patients who underwent lung transplantation from 2008 to 2012 experienced left ventricular dysfunction (five out of 16 patients) [56].…”

“…The scale of this complication was demonstrated in a retrospective single-centre study, where almost a third of PAH patients who underwent lung transplantation from 2008 to 2012 experienced left ventricular dysfunction (five out of 16 patients) [56]. To avoid left ventricular dysfunction, use of ECMO can be prolonged into the post-operative period in order to allow time for the left ventricle to adapt to the altered haemodynamics that occur after transplantation [54].…”

Triple Cannulation ECMO

“…A bridgeto-decision strategy [39] is followed in patients after resuscitation, with the intention to gain time, while end organ perfusion is improved until neurological outcome after resuscitation can be evaluated. The use of VA-ECMO is further beneficial during the early postoperative phase after lung transplantation, while the heart is not ready to manage reconstituted left ventricular preload [40]. As in recent years, efforts are made to improve the outcome after outof-hospital resuscitation, and VA-ECMO will also play an important role here [41], since available outcome data suggest a benefit in this context [42,43].…”

Cannulation techniques for extracorporeal life support

“…The main objective of ECLS is to provide systemic perfusion and gas exchange allowing the heart and lungs to rest and recover or bridge the patient to another modality of mechanical support or transplantation (1)(2)(3)(4)(5)(6). The technology involves redirecting the blood from the body through cannulas and connecting tubing to gas-exchange membrane and then returning it by means of a pump back to the patient's circulation.…”