Mechanical Ventilation and Extracorporeal Membrane Oxygenation as a Bridging Strategy to Lung Transplantation: Significant Gains in Survival

Abstract

Mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO) are increasingly used to bridge patients to lung transplantation. We investigated the impact of using MV, with or without ECMO, before lung transplantation on survival after transplantation by performing a retrospective analysis of 826 patients who underwent transplantation at our high-volume center. Recipient characteristics and posttransplant outcomes were analyzed. Most lung transplant recipients (729 patients) did not require bridging; 194 of these patients were propensity matched with patients who were bridged using MV alone (48 patients) or MV and ECMO (49 patients). There was no difference in overall survival between the MV and MV+ECMO groups (p = 0.07). The MV+ECMO group had significantly higher survival conditioned on surviving to 1 year (median 1,811 days ([MV] vs. not reached ([MV+ECMO], p = 0.01). Recipients in the MV+ECMO group, however, were more likely to require ECMO after lung transplantation (16.7% MV vs. 57.1% MV+ECMO, p < 0.001). There were no differences in duration of postoperative MV, hospital stay, graft survival, or the incidence of acute rejection, renal failure, bleeding requiring reoperation, or airway complications. In this contemporary series, the combination of MV and ECMO was a viable bridging strategy to lung transplantation that led to acceptable patient outcomes.

Elderly patients with multiple comorbidities: insights from the bedside to the bench and programmatic directions for this new challenge in lung transplantation

“…High‐volume transplant centers are privileged as the leaders of the field to spearhead future directions in lung transplantation by pushing the envelope while demonstrating consistently improving transplant outcomes. For instance, recently, in high‐volume centers, there has been a paradigm shift toward performing lung transplant in patients with lung allocation scores in the highest tertile and a softening of attitudes toward the use of respiratory support before lung transplantation, such as prior mechanical ventilation and extracorporeal lung support (ECLS) including extracorporeal membrane oxygenation (ECMO), as was reported elsewhere . In fact, accumulating evidence supports using ECMO and ECLS to treat lung failure and support patients before and after lung transplantation, and the success of ECLS in lung transplantation sheds a new light on expanding its use toward long‐term artificial respiratory support for advanced lung failure .…”

Getting to transplantation

“…Hayanga and colleagues elect to examine candidates bridged to transplantation with iMV and/or ECMO, and compare them in a matched fashion to those who did not require iMV . They exclude candidates who required ECMO but not iMV, as well as those who required ECMO or iMV but were not successfully bridged to transplantation.…”

Chronic Obstructive Pulmonary Disease and Lung Transplantation

“…60 Technological advances and increasing clinical experience have, however, improved to the extent that post-LTx outcomes in ECMO patient may approach non-ECMO patients, particularly in high-volume centers. [61][62][63] Caution in interpretation is again required, with registry analyses, almost exclusively based on UNOS data. COPD was the smallest disease group in the ECMO category accounting for only 15% of patients in the initial analyses, falling to 6% in subsequent studies.…”

“…COPD was the smallest disease group in the ECMO category accounting for only 15% of patients in the initial analyses, falling to 6% in subsequent studies. 61,63 Equally, all ECMO patients had been ventilated making causality difficult to ascertain. In some centers, ECMO in nonintubated patients, to ameliorate the disadvantages of prolonged MV, has been successfully introduced, with improved early survival compared with MV (80 vs. 50% at 6 months).…”