Outcomes and temporal trends among high-risk patients after lung transplantation in the United States

Abstract

Introduction: Although several studies have evaluated risk factors for mortality after lung transplantation (LTx), few studies have focused on the highest risk recipients. We undertook this study to evaluate the impact of high lung allocation scores (LAS), ventilator support, and extracorporeal membrane oxygenation (ECMO) support on outcomes after LTx. Methods: We retrospectively reviewed all LTx recipients in the United Network for Organ Sharing database. Primary stratification was by recipient acuity at the time of LTx. The three strata consisted of: (1) recipients in the highest LAS quartile (LAS≥48.4); (2) those requiring ventilator support; and (3) those requiring ECMO support. The primary outcome was 1-year mortality. Subgroup analysis focused on temporal trends. Results: From 05/2005-06/2011, 9,267 adult patients underwent LTx. Prior to LTx, 1,874 (20.2%) were in the highest LAS quartile, 526 (5.7%) required ventilator support, and 122 (1.3%) required ECMO support. On unadjusted analysis, ventilator and ECMO support were both associated with decreased 1-year survival compared to those in the highest LAS quartile (High LAS: 81.0% vs. Vent: 67.7% vs. ECMO: 57.6%, p<0.001 for each comparison). These differences persisted on adjusted analysis (Ventilator support, HR: 1.99, p<0.001; ECMO support, HR: 3.03, p<0.001). Increasing annual center volume was associated with decreased mortality. In patients bridged to LTx with ECMO support, 1-year survival improved over time (Coefficient: 8.03%/year, p=0.06). Conclusions: High acuity LTx recipients, particularly those bridged with ventilator or ECMO support, have increased short-term mortality after LTx. However, since the introduction of the LAS, high-risk patients have demonstrated improving outcomes, particularly at high volume centers.

Extracorporeal membrane oxygenation in the pre and post lung transplant period

“…Inappropriate patient selection and delayed deployment of ECMO technology have been significant predictors of poor patient outcomes (19,25). Unfortunately, there are no universally accepted guidelines available, and individual institutional practices dominate the decisions to bridge a patient on ECMO.…”

“…Additionally, these patients should have a good nutritional status, moderate functional status and/or the perceived ability to rehabilitate while on ECMO support (19,27). Early consideration of ECMO in the management algorithm of these decompensating patients appears to result in more favorable outcomes.…”

“…Patients requiring ECMO are more severely ill and thus have a higher lung allocation score (LAS), which is advantageous for lung transplant listing (16). Initial studies after the inception of LAS scoring noted that one-year outcomes in patients with higher LAS (17) and patients bridged with ECMO were lower (18,19). However, more recent studies analyzing the UNOS database have showed that outcomes in ECMO patient's post-lung transplant may be similar to non-ECMO patients, especially in centers with higher transplant volumes and experience (20,21).…”

Novel Uses of Extracorporeal Membrane Oxygenation in Adults

“…37 However, with the advent of improved circuitry with lower complication rates, more experience with its use, and institution of ECMO earlier in a patient's course, recent studies have demonstrated significantly improved posttransplant outcomes. [38][39][40][41][42] The use of upperbody configurations help to facilitate rehabilitation, including ambulation, which has the benefit of maintaining-or even improving-physical conditioning and, consequently, transplant candidacy. 11,15,43,44 For select patients, ECMO may provide sufficient gas exchange to allow for the removal of invasive mechanical ventilation, further facilitating mobilization while eliminating the risks associated with invasive mechanical ventilation.…”

87 Coronary Revascularization in Lung Transplant Recipients with Concomitant Coronary Artery Disease

“…As advances in lung transplantation continue to expand the donor pool (12)(13)(14) and improve outcomes in high-risk recipients (15), it is increasingly likely that transplant teams will need to address occult CAD in lung transplant candidates.…”