Spontaneously Breathing Extracorporeal Membrane Oxygenation Support Provides the Optimal Bridge to Lung Transplantation

Abstract

Background Extracorporeal membrane oxygenation (ECMO) is being increasingly used as a bridge to lung transplantation. Small, single-institution series have described increased success using ECMO in spontaneously breathing patients compared with patients on ECMO with mechanical ventilation, but this strategy has not been evaluated on a large scale. Methods Using the United Network for Organ Sharing database, all adult patients undergoing isolated lung transplantation from May 2005 through September 2013 were identified. Patients were categorized by their type of pretransplant support: no support, ECMO only, invasive mechanical ventilation (iMV) only, and ECMO + iMV. Kaplan-Meier survival analysis with log-rank testing was performed to compare survival based on type of preoperative support. A Cox regression model was used to determine whether type of preoperative support was independently associated with survival, using previously established predictors of survival as covariates. Results Approximately 12,403 primary adult pulmonary transplantations were included in this analysis. Sixty-five patients (0.52%) were on ECMO only, 612 (4.93%) required only iMV, 119 (0.96%) were on ECMO + iMV, and the remaining 11,607 (94.6%) required no invasive support before transplantation. One-year survival was decreased in all patients requiring support, regardless of type. However, mid-term survival was similar between patients on ECMO alone and those not on support but significantly worse with patients requiring iMV only or ECMO + iMV. In multivariable analysis, ECMO + iMV and iMV alone were independently associated with decreased survival compared with nonsupport patients, whereas ECMO alone was not significant. Conclusions In patients with worsening pulmonary disease awaiting lung transplantation, those supported via ECMO with spontaneous breathing demonstrated improved survival compared with other bridging strategies.

Lung Transplantation in Germany Since the Introduction of the Lung Allocation Score

“…The outcomes of transplantation in patients receiving extracorporeal support in Germany seem to be markedly worse than in the USA. More than twice as many patients in this group received lung transplants in Germany (13% vs. 6.4%) (18).…”

Extracorporeal membrane oxygenation as a bridge to lung transplantation: analysis of Korean organ transplantation registry (KOTRY) data

“…ECMO support improves outcomes in patients with life-threatening respiratory failure [11] and the application of ECMO as a rescue therapy is expanding in clinical practice [20]. In addition, ECMO has become a lifesaving intervention for a subset of rapidly deteriorating patients with end-stage lung disease, which offers optimizing gas exchange and end-organ perfusion to patients who might otherwise die before a suitable donor [23]. In contrast, Inci et al showed worse overall and 3 month conditional survivals in the bridge-ECMO group (n = 26) versus the non-bridge-ECMO group (n = 160) (68% versus 85%, p = 0.001; 86% versus 92%, p = 0.03, respectively) [15].…”

Getting to transplantation

“…Recently, the increasing use of ECMO as a bridging strategy to lung transplantation at the national level was evaluated. According to registry data, 6.4% of candidates in the United States required invasive respiratory support (ECMO and/or iMV) prior to LTX, and while recipients requiring iMV (with or without ECMO) were at a survival disadvantage, nonintubated recipients requiring ECMO suffered no detriment in survival as compared to recipients requiring no support at the time of transplant . In contradistinction, this month, Hayanga et al share their single‐center experience in a retrospective cohort study, permitting an alternative appraisal of these support strategies in their hands.…”

“…Specifically, granular details with respect to the nature of pre‐LTX ECMO support are lacking. Single‐center and registry data have shown the importance of awake and active‐rehab approaches to ECMO that were not able to be described in this work . In addition, bias in organ offer acceptance in candidates requiring ECMO may warrant further description.…”