Lung transplantation via cardiopulmonary bypass: excellent survival outcomes from extended criteria donors

Abstract

Objectives The role of intraoperative cardiopulmonary bypass (CPB) in lung transplant (LTx) surgery is controversial. CPB enables slow pulmonary reperfusion and initial ventilation with low oxygen concentrations, both theoretically protective of transplanted lungs. In this study, we explored clinical outcomes following extended criteria donor LTx surgery implementing a thoroughly protective allograft reperfusion strategy using CPB. Methods Thirty-nine consecutive adult patients who underwent bilateral LTx with elective CPB and protective allograft reperfusion were reviewed. Bilaterally implanted lungs were reperfused simultaneously, via slow CPB flow reduction and initial ventilation with 21% oxygen and nitric oxide, followed by a brief modified ultrafiltration. During weaning from CPB, mean pulmonary arterial pressure was strictly maintained at 10-15 mmHg by controlling CPB and pulmonary flow. The clinical outcomes in 23 patients who received lungs from extended criteria donors (ECD group) were elucidated and compared to 16 patients undergoing LTx from standard criteria donors (SCD group). Results No life-threatening deterioration was observed to graft functionality during the first 72 h after LTx in the ECD group; however, only one patient required post-transplant extracorporeal membrane oxygenation. In three of 23 ECD LTx patients (12%), surgical revision for bleeding was required. Survival outcomes for the ECD group were favorable, with 100% survival at 6-months, 87.0% at 1-year, and 80.7% at 5-years. Outcomes in the ECD group were comparable to those in the SCD group. Conclusions Despite a certain extent of risk associated with full-dose heparinization, use of CPB does not undermine survival outcomes after ECD LTx surgery if protective allograft reperfusion is securely performed.

Bilateral sequential lung transplantation in Kartagener syndrome

“… 7 However, it can limit cardiac drainage and heart manipulation owing to the preload-dependent nature of the centrifugal pump, lack of venous reservoir, and suboptimal flow control. 8 Nevertheless, a stable hemodynamic state was achieved in both of our patients with ECMO support.…”

Intraoperative support during lung transplantation

“…CPB provides essential points like complete control of the patients' hemodynamic status, allowing an easy way to handle critical events during LTx (32) and historically is associated with good outcomes after transplantation (33,34). The technique of CPB is described in detail elsewhere (35).…”

Extracorporeal life support during lung transplantation

“…CPB stabilizes patient hemodynamics during transplantation and maintains oxygenation while allowing for protective ventilation strategies or minimal ventilation of the reperfusing allograft. Some centers have advocated the use of CPB because it allows for the slow initiation of pulmonary reperfusion and low oxygen concentrations during initial ventilation [8]. One benefit of using CPB during lung transplantation is improved volume control and drainage of the heart.…”

“…Yet, several studies have demonstrated techniques that allow for slow pulmonary reperfusion of the allograft, which may protect the newly implanted lungs. Taka and colleagues [8] describe their use of CPB with extended criteria donor lungs to maintain slow reperfusion and protect these more susceptible allografts. They preferred to use CPB with every bilateral lung transplantation.…”

“…Furthermore, early outcomes of patients who received extended criteria lungs were comparable to those of patients who received standard criteria donor allografts in terms of postoperative mechanical ventilator support times, necessity for postoperative ECMO support, and intensive care and hospital lengths of stay. The authors reported having better control of reperfusion, which they attributed to improved control of CPB flows when compared with ECMO [8]. The lung transplantation team at the Medical University of Vienna [24] described their technique of controlled reperfusion when utilizing ECMO support.…”