Extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation: long-term survival. Ann Thorac Surg. 2009;87:854-860. [PMID: 19231405 DOI: 10.1016/j.athoracsur.2008.11.036]

Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica

In origine, l’extracorporeal membrane oxygenation (ECMO) era una tecnica di assistenza respiratoria che utilizzava uno scambiatore gassoso a membrana. Per estensione, l’ECMO è diventata una tecnica respiratoria e cardiopolmonare utilizzata in caso di deficit respiratorio e/o cardiaco nell’attesa della restaurazione della funzione deficitaria o di un eventuale trapianto. Il supporto emodinamico può essere parziale o totale. Gli accessi vascolari possono essere periferici o centrali. Questo tipo di assistenza utilizza il concetto di circolazione extracorporea (CEC) sanguigna che in epoca moderna si è estesa con l’utilizzo di polmoni artificiali a membrana. Il circuito di base è semplice e comprende una pompa, un ossigenatore (che permette al sangue di caricarsi di O₂ e di eliminare CO₂) e delle vie d’accesso (una di drenaggio e una di reinfusione). La sua attuazione è facile, veloce e può essere avviata al letto del malato. Il miglioramento delle attrezzature, una migliore conoscenza delle tecniche e delle indicazioni, e le politiche di salute pubblica hanno reso popolare questa tecnica. Alcuni centri di chirurgia toracica la utilizzano di routine come assistenza alla realizzazione di un intervento terapeutico (soprattutto trapianto) assieme a team di rianimazione per il trattamento della sindrome da distress respiratorio acuto. Nel quadro della malattia polmonare dell’adulto, l’idea principale è quella di sviluppare il concetto di strategia minimalista con l’uso di una CEC adiuvante parziale – più che sostitutiva totale – che permetterebbe il recupero metabolico ad integrum del paziente. Nei prossimi anni, i progressi della tecnologia e dell’ingegneria così come le conoscenze approfondite permetteranno il miglioramento della prognosi dei pazienti colpiti da deficit respiratorio sotto assistenza meccanica.

Vascular access for extracorporeal life support: tips and tricks

In thoracic surgery, extracorporeal life support (ECLS) techniques are performed to (I) provide a short to mid term extracorporeal mechanical support; (II) realize the gas exchanges; and (III)-depending the configuration of the circuit-substitute the failed heart function. The objective of this review is to describe the rational of the different ECLS techniques used in thoracic surgery and lung transplantation (LTx) with a specific attention to the vascular access. Venovenous extracorporeal membrane oxygenation (VV ECMO) is the most common ECLS technique used in thoracic surgery and represents the best strategy to support the lung function. VV ECMO needs peripheral vascular access. The selection between his double-site or single-site configuration should be decided according the level of O2 requirements, the nosological context, and the interest to perform an ECLS ambulatory strategy. Venoarterial (VA) ECMO uses peripheral and/or central cannulation sites. Central VA ECMO is mainly used in LTx instead a conventional cardiopulmonary bypass (CPB) to decrease the risk of hemorrhagic issues and the rate of primary graft dysfunction (PGD). Peripheral VA ECMO is traditionally realized in a femoro-femoral configuration. Femoro-femoral VA ECMO allows a cardiocirculatory support but does not provide an appropriate oxygenation of the brain and the heart. The isolated hypercapnic failure is currently supported by extracorporeal CO2 removal (ECCO2R) devices inserted in jugular or subclavian veins. The interest of the Novalung (Novalung GmbH, Hechingen, Germany) persists due to his central configuration indicated to bridge to LTx patients suffering from pulmonary hypertension. The increasing panel of ECLS technologies available in thoracic surgery is the results of a century of clinical practices, engineering progress, and improvements of physiological knowledges. The selection of the ECLS technique-and therefore the vascular access to implant the device-for a given nosological context trends to be defined according an evidence-based medicine.

Concepts from paediatric extracorporeal membrane oxygenation for adult intensivists

Over the last 5 years, there has been a dramatic increase in the use of extracorporeal membrane oxygenation (ECMO) in adult patients with severe respiratory or cardiac failure. This contrasts to the use of the technology in neonatal and paediatric intensive care units, where it has been regarded as a standard of care for a number of conditions for over 25 years. Many innovations in ECMO circuitry or clinical management evolve first in one particular discipline and it may be helpful for individual clinicians to keep abreast of developments in ECMO across the entire age range, from neonatology to older adults. This review addresses nine concepts in ECMO that are better studied or established in paediatric medicine and considers their application in adult patients.

Biocompatibility Assessment of the CentriMag-Novalung Adult ECMO Circuit in a Model of Acute Pulmonary Hypertension

Extracorporeal membrane oxygenation (ECMO) is rarely used in patients with severe pulmonary hypertension (PH) as a bridge to lung transplantation. In this study, we assess the blood biocompatibility of the integrated CentriMag-Novalung ECMO system (venoarterial) in an acute model of PH. Severe PH (≥2/3 systemic) was induced in eight sheep through progressive ligation of the main pulmonary artery. System performance, platelet activation, thromboelastography (TEG) parameters, fibrinogen, plasma-free hemoglobin, and total plasma protein were measured at initiation, 3, and 6 hr of support in the ECMO (N = 4) and sham (N = 4) groups. A stable ECMO flow (2.2 ± 0.1 L/min), low transmembrane pressure gradient, and steady blood O2 and CO2 levels were maintained. Platelet activation was low (<4%) in both the groups, whereas platelet responsiveness to agonist (platelet activating factor) was reduced in the sham group when compared with the ECMO group. There were no differences in the TEG parameters, fibrinogen concentration, plasma-free hemoglobin (<10 mg/dl), and plasma total protein between the two groups. The findings of low levels of platelet activation and plfHb suggest adequate blood biocompatibility of the integrated CentriMag-Novalung circuit use for short-term support in a model of PH.

Donor-acquired fat embolism syndrome after lung transplantation

OBJECTIVES

Fat embolism is a known complication of severe trauma and closed chest cardiac resuscitation both of which are more common in the lung transplant donor population and can lead to donor-acquired fat embolism syndrome (DAFES). The objective was to review the diagnosis and management of DAFES in the lung transplantation literature and at our centre.

METHODS

We performed a literature review on DAFES using the Medline database. We then reviewed the transplant record of Brigham and Women's Hospital, a large academic hospital with an active lung transplant programme, for cases of DAFES.

RESULTS

We identified 2 cases of DAFES in our centre, one of which required extracorporeal membrane oxygenation (ECMO) for successful management. In contrast to the broader literature on DAFES, which emphasizes unsuccessfully treated cases, both patients survived.

CONCLUSION

DAFES is a rare but likely underappreciated early complication of lung transplant as it can mimic primary graft dysfunction. Aggressive interventions, including ECMO, may be necessary to achieve a good clinical outcome following DAFES.

Primary graft dysfunction: lessons learned about the first 72 h after lung transplantation

PURPOSE OF REVIEW

In 2005, the International Society for Heart and Lung Transplantation published a standardized definition of primary graft dysfunction (PGD), facilitating new knowledge on this form of acute lung injury that occurs within 72 h of lung transplantation. PGD continues to be associated with significant morbidity and mortality. This article will summarize the current literature on the epidemiology of PGD, pathogenesis, risk factors, and preventive and treatment strategies.

RECENT FINDINGS

Since 2011, several manuscripts have been published that provide insight into the clinical risk factors and pathogenesis of PGD. In addition, several transplant centers have explored preventive and treatment strategies for PGD, including the use of extracorporeal strategies. More recently, results from several trials assessing the role of extracorporeal lung perfusion may allow for much-needed expansion of the donor pool, without raising PGD rates.

SUMMARY

This article will highlight the current state of the science regarding PGD, focusing on recent advances, and set a framework for future preventive and treatment strategies.

[The place of extra-corporeal oxygenation in pulmonary diseases]

Extra-corporeal membrane oxygenation (ECMO) effectively replaces the lung in providing oxygenation and carbon dioxide (CO2) removal. For some years, and in parallel to the H1N1 influenza pandemic, this technique has gained interest in relation to significant technological improvements, leading to new concepts of "awake and mobile ECMO" or rehabilitation with ECMO. Finally, the publication of randomized controlled trials giving encouraging results in the adult respiratory distress syndrome (ARDS) has helped to validate this technique and further studies are warranted. This general review aims to outline the definition, classification and principles of ECMO and to give some current information about the indications and possibilities of the technique to the pulmonologist and intensivist. Further possible uses for this technique include extra-corporeal removal of CO2 during hypercapnic respiratory failure and assistance during lung transplantation from the preoperative to the early postoperative period.

Outcomes of intraoperative extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation

OBJECTIVE

The study objective was to compare the outcomes of intraoperative extracorporeal membrane oxygenation versus cardiopulmonary bypass support in lung transplantation.

METHODS

We performed a retrospective cohort study from a prospective database of adult lung transplantations performed at the University of Toronto from 2007 to 2013. Among 673 lung transplantations performed in the study period, 267 (39.7%) required cardiopulmonary support. There were 39 cases of extracorporeal membrane oxygenation (2012-2013) and 228 cases of cardiopulmonary bypass (2007-2013). Patients who were bridged with extracorporeal life support, underwent a concomitant cardiac procedure, received a combined liver or heart transplant, were colonized with Burkholderia cenocepacia, or required emergency cannulation for cardiopulmonary support were excluded. Finally, 33 extracorporeal membrane oxygenation cases were matched with 66 cases of cardiopulmonary bypass according to age (±10 years), lung transplantation indication, and procedure type (bilateral vs single lung transplantation).

RESULTS

Recipient factors such as body mass index and gender were not different between extracorporeal membrane oxygenation and cardiopulmonary bypass groups. Furthermore, donor variables were similar, including age, body mass index, last PaO2/FiO2 ratio, smoking history, positive airway cultures, and donor type (brain death and donation after cardiac death). Early outcomes, such as mechanical ventilation requirement, length of intensive care unit stay, and length of hospital stay, significantly favored extracorporeal membrane oxygenation (median 3 vs 7.5 days, P = .005; 5 vs 9.5 days, P = .026; 19 vs 27 days, P = .029, respectively). Perioperative blood product transfusion requirement was lower in the extracorporeal membrane oxygenation group. The 90-day mortality for the extracorporeal membrane oxygenation group was 6% versus 15% for cardiopulmonary bypass (P = .32).

CONCLUSIONS

Extracorporeal membrane oxygenation may be considered as the first choice of intraoperative cardiorespiratory support for lung transplantation.

Outcomes of intraoperative venoarterial extracorporeal membrane oxygenation versus cardiopulmonary bypass during lung transplantation

BACKGROUND

The intraoperative use of cardiopulmonary bypass (CPB) in lung transplantation has been associated with increased rates of pulmonary dysfunction and bleeding complications. More recently, extracorporeal membrane oxygenation (ECMO) has emerged as a valid alternative method of support and has been our preferred method of support since March 2012. We compared early and midterm outcomes of these 2 support methods.

METHODS

Between July 2007 and April 2013, 271 consecutive patients underwent lung transplant using CPB (n = 222) or ECMO (n = 49). We retrospectively reviewed the outcomes of these patients requiring CPB or ECMO during lung transplant.

RESULTS

The CPB and ECMO groups had comparable demographic and operative characteristics; however, the ECMO group had higher mean lung allocation scores (73 vs 52, p < 0.001). In the CPB group, more patients required reintubation (35.6% vs 20.4%, p = 0.04) or temporary tracheostomy (44.6% vs 28.6%, p = 0.05). Patients in the CPB group had a higher rate of renal failure requiring dialysis than the ECMO group (22.1% vs 8.2 %, p = 0.028). There were no differences in severe PGD requiring postoperative circulatory support (p = 0.83) or the need for perioperative red blood cell transfusions (p = 0.64) between the groups. No differences in 30-day (5% CPB vs 4.1% ECMO) or 6-month mortality (14.4% CPB vs 14.3% ECMO) were noted.

CONCLUSIONS

The use of ECMO in lung transplant is safe and in our experience was associated with decreased rates of pulmonary and renal complications, as compared with CPB. Extracorporeal membrane oxygenation has become our preferred method of intraoperative support during lung transplantation.

Extracorporeal life support in critically ill adults

Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.

Extracorporeal membrane oxygenation and retransplantation in lung transplantation: an analysis of the UNOS registry

BACKGROUND

Despite limited organ availability, extracorporeal membrane oxygenation (ECMO) and retransplantation are becoming more commonplace.

METHODS

Using the United Network for Organ Sharing (UNOS) database, we evaluated survival of patients treated with ECMO before lung transplantation and undergoing retransplantation. A query identified cadaveric recipients from 2001 to 2012 over the age of 6 years.

RESULTS

Of 15,772 lung recipients, 15 583 never received ECMO, whereas 189 did. Mean age was 52.1 ± 14.4 versus 46.8 ± 16.5 years for non-ECMO and ECMO groups, respectively (p < 0.0001). Using Kaplan-Meier method, there were survival differences between ECMO and non-ECMO groups (p < 0.0001) and first-time transplants with and without ECMO to retransplants with and without ECMO (p < 0.0001). The proportional hazards model identified higher risk with ECMO use in idiopathic pulmonary fibrosis (hazard ratio [HR] 1.09; 95 % confidence interval (CI), 1.02-1.17; p = 0.014) and retransplants (HR 1.77; 95 % CI, 1.55-2.03; p < 0.0001).

CONCLUSIONS

Survival for retransplantation was similar to ECMO as a primary option with significant mortality associated with ECMO use in patients with idiopathic pulmonary fibrosis and retransplants.

Primary graft dysfunction

Primary graft dysfunction (PGD) is a syndrome encompassing a spectrum of mild to severe lung injury that occurs within the first 72 hours after lung transplantation. PGD is characterized by pulmonary edema with diffuse alveolar damage that manifests clinically as progressive hypoxemia with radiographic pulmonary infiltrates. In recent years, new knowledge has been generated on risks and mechanisms of PGD. Following ischemia and reperfusion, inflammatory and immunological injury-repair responses appear to be key controlling mechanisms. In addition, PGD has a significant impact on short- and long-term outcomes; therefore, the choice of donor organ is impacted by this potential adverse consequence. Improved methods of reducing PGD risk and efforts to safely expand the pool are being developed. Ex vivo lung perfusion is a strategy that may improve risk assessment and become a promising platform to implement treatment interventions to prevent PGD. This review details recent updates in the epidemiology, pathophysiology, molecular and genetic biomarkers, and state-of-the-art technical developments affecting PGD.

[Extracorporeal membrane oxygenation in primary graft dysfunction in a paediatric double lung transplant: presentation of a case]

Primary graft dysfunction is a leading cause of morbimortality in the immediate postoperative period of patients undergoing lung transplantation. Among the treatment options are: lung protective ventilatory strategies, nitric oxide, lung surfactant therapy, and supportive treatment with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery of lung function or re-transplant. We report the case of a 9-year-old girl affected by cystic fibrosis who underwent double-lung transplantation complicated with a severe primary graft dysfunction in the immediate postoperative period and refractory to standard therapies. Due to development of multiple organ failure, it was decided to insert arteriovenous ECMO catheters (pulmonary artery-right atrium). The postoperative course was satisfactory, allowing withdrawal of ECMO on the 5th post-surgical day. Currently the patient survives free of rejection and with an excellent quality of life after 600 days of follow up.

Primary graft dysfunction does not lead to increased cardiac allograft vasculopathy in surviving patients

OBJECTIVE

Early injury is associated with the development of cardiac allograft vasculopathy in heart transplantation. We examined whether adult heart transplant recipients surviving primary graft dysfunction were more susceptible to the development of cardiac allograft vasculopathy than their nonprimary graft dysfunction counterparts.

METHODS

A total of 857 patients who underwent heart transplantation between January 1994 and December 2008 at our institution were reviewed. Primary graft dysfunction was defined as the need for extracorporeal membrane oxygenation, open chest, or intra-aortic balloon pump placement within 72 hours of transplantation. Cardiac allograft vasculopathy was defined as ≥50% coronary artery stenosis in any vessel. Allograft survival was defined by patient death or need for retransplantation.

RESULTS

Completed follow-up was available for 32 patients in the primary graft dysfunction group and 701 patients in the nonprimary graft dysfunction group. Mean recipient ages (56 years vs 55 years, respectively; P = .50) and ischemic times (220 minutes vs 208 minutes, respectively; P = .35) were similar. Donor age was significantly higher in the primary graft dysfunction group (38 years vs 32 years, P = .02). Five-year survivals for the primary graft dysfunction and nonprimary graft dysfunction groups were 46.9% versus 78.9% (P < .001). Conditional 5-year survivals in patients surviving the first year were 78.9% and 88.3% for the primary graft dysfunction and nonprimary graft dysfunction groups, respectively (P = .18). Within a 30-day postoperative period, there were more deaths in the primary graft dysfunction group (28.1% vs 2.3%, P < .0001) and more retransplants (6.25% vs 0%, P = .002). Of the patients surviving past 30 days, only 2 (8.7%) of the primary graft dysfunction patients developed cardiac allograft vasculopathy versus 144 (21.0%) in the nonprimary graft dysfunction group (P < .001).

CONCLUSIONS

Primary graft dysfunction was associated with lower 30-day, 1-year, and 5-year allograft survival rates. Surviving patients, however, did not show increased tendency toward cardiac allograft vasculopathy development.

[Extracorporeal lung support]

For decades, techniques for extracorporeal lung support, such as extracorporeal membrane oxygenation (ECMO), have offered in specialized centres the possibility to completely or partly substitute lung function, thus, facilitating healing. Initially the application of ECMO was associated with severe complications, but significant technical progress in recent years has led to the development of safer systems and promotes a wider distribution of the technique. Supported by recent, positive study data, ECMO has become a promising option for acute respiratory distress syndrome (ARDS) therapy in specialized centers. Further developments and modifications, such as pumpless devices for extracorporeal lung support have the potential of becoming an interesting option for intensive care medicine - however, data of prospective studies showing efficacy are still not available.

Outcome of extracorporeal membrane oxygenation as a bridge to lung transplantation and graft recovery

BACKGROUND

Indications for extracorporeal membrane oxygenation (ECMO) use in lung transplantation are (1) temporary assistance as a bridge to transplantation, (2) stabilization of hemodynamics during transplantation in place of cardiopulmonary bypass, and (3) treatment of severe lung dysfunction and primary graft failure after transplantation. This study compares the survival of lung transplant recipients requiring ECMO support with survival of patients without ECMO.

METHODS

A retrospective database review was performed for 108 consecutive patients who underwent single-lung or bilateral-lung transplantation at our center between 2002 and 2009.

RESULTS

Of 108 transplant recipients, 27 (25%) required venoarterial ECMO compared with 81 patients who did not. Nine patients required ECMO preoperatively (87±102 hours), and ECMO was continued for 5 patients during the lung transplant operation. Seven additional patients received ECMO during transplantation. Six patients required early (<7 days) and 5 patients delayed (≥7 days) postoperative ECMO for treatment of allograft dysfunction. The subgroup with support showed the most favorable patient discharge rate (66.7%). ECMO support was a significant risk factor for death (p<0.001). Survival was significantly reduced with the use of ECMO: 30-day, 90-day, 1-year, and 5-year survival was 97%, 91%, 83%, and 58% in the patients without ECMO compared with 63%, 44%, 33%, and 21% in those with ECMO, respectively.

CONCLUSIONS

Survival after lung transplantation was significantly reduced with ECMO. However, patients who survived the first year showed similar long-term survival as those patients who did not need perioperative ECMO support.

Critical care management of the lung transplant recipient

Lung transplantation provides the prospect of improved survival and quality of life for patients with end stage lung and pulmonary vascular diseases. Given the severity of illness of such patients at the time of surgery, lung transplant recipients require particular attention in the immediate post-operative period to ensure optimal short-term and long-term outcomes. The management of such patients involves active involvement of a multidisciplinary team versed in common post-operative complications. This review provides an overview of such complications as they pertain to the practitioners caring for post-operative lung transplant recipients. Causes and treatment of conditions affecting early morbidity and mortality in lung transplant recipients will be detailed, including primary graft dysfunction, cardiovascular and surgical complications, and immunologic and infectious issues. Additionally, lung donor management issues and bridging the critically ill potential lung transplant recipient to transplantation will be discussed.

[Primary graft dysfunction after lung transplantation]

Lung transplantation is a therapeutic option for pulmonary diseases in which the other treatment options have failed or in cases of rapid disease progression. However, transplantation is not free from complications, and primary graft dysfunction is one of them. Primary graft dysfunction is a form of acute lung injury. It characteristically develops during the immediate postoperative period, being associated to high morbidity and mortality, and increased risk of bronchiolitis obliterans. Different terms have been used in reference to primary graft dysfunction, leading to a consensus document to clarify the definition in 2005. This consensus document regards primary graft dysfunction as non-cardiogenic pulmonary edema developing within 72 hours of reperfusion and intrinsically attributable to alteration of the lung parenchyma. A number of studies have attempted to identify risk factors and to establish the underlying physiopathology, with a view to developing potential therapeutic options. Such options include nitric oxide and pulmonary surfactant together with supportive measures such as mechanical ventilation or oxygenation bypass.

Current status of lung transplantation

Lung transplantation is a well-established treatment option for selected patients with end-stage lung disease, leading to improved survival and improved quality of life. The last 20 years have seen a steady growth in number of lung transplantation procedures performed worldwide. The increase in clinical activity has been associated with tremendous progress in the understanding of cellular and molecular processes that limit both short- and long-term outcomes. This review gives a comprehensive overview of the current status of lung transplantation for the referring physician. It demonstrates that careful selection of potential recipients, optimisation of their condition prior to transplant, use of carefully assessed donor organs, excellent surgery and meticulous long-term follow-up are all essential ingredients in determining a successful outcome.

Institution of extracorporeal membrane oxygenation late after lung transplantation - a futile exercise?

The use of and indications for extracorporeal membrane oxygenation (ECMO) are expanding as its reliability improves with widely varying results reported. A retrospective review of 24 lung transplant recipients who required ECMO support postoperatively was performed with 13 patients requiring ECMO within the first 48 h ("early" group) and 11 requiring ECMO after seven d postoperatively ("late" group). The majority of early ECMO group had primary graft failure patients and the late ECMO group comprised patients with infection or non-specific graft failure. There were significant differences in outcomes between groups, with 10/13 in the early group and 4/11 in the late group successfully weaned from ECMO (p = 0.045). Six of the 13 patients in the early group and none of the late group survived to hospital discharge (p = 0.009). The late ECMO group had a much higher incidence of death owing to complications existing prior to institution of ECMO (essentially uncontrolled infection or organ failure). There were no differences in complications arising during ECMO between groups. Late institution of ECMO in lung transplant recipients for causes other than primary graft failure is associated with such poor survival that its use should be considered only in very select cases.

Successful lung retransplantation after extended use of extracorporeal membrane oxygenation as a bridge

Redo lung transplantation remains a major clinical challenge and its indication for patients with early allograft dysfunction is difficult to determine. We report a case of potentially fatal early allograft dysfunction owing to possible acute cellular rejection after single lung transplantation in a patient who underwent redo double lung transplantation after successful use of extracorporeal membrane oxygenation as a bridge, which resulted in a successful outcome.

Improved survival but marginal allograft function in patients treated with extracorporeal membrane oxygenation after lung transplantation

BACKGROUND

Previous reports demonstrate that 1-year survival is severely compromised in patients with severe primary graft dysfunction (PGD) after lung transplantation. We examined if advances in extracorporeal membrane oxygenation (ECMO) support, including polymethylpentene oxygenators and reliance on venovenous (VV) ECMO have improved outcomes in patients with severe PGD after lung transplantation.

METHODS

The analysis included data prospectively collected on all single-lung or double-lung transplants between November 2001 and December 2009. Heart-lung transplants were excluded. Comparisons were made between recipients who did and did not require ECMO for PGD after transplant.

RESULTS

Since November 2001, when VV ECMO became the routine treatment for severe PGD after transplant at our center, 28 of 498 patients (6%) have required VV ECMO support. Successful weaning occurred in 27 of 28 (96%). Support was withdrawn for 1 patient with irreversible neurologic injury. Survival was substantially better than in previous reports: 30 days, 82%; 1 year, 64%; and 5 years, 49%. Freedom from bronchiolitis obliterans syndrome was 88% in the ECMO survivors at 3 years, but maximum allograft function was considerably worse than in transplant recipients not requiring ECMO (peak forced expiratory volume in 1 second: 58% in ECMO vs 83% in non-ECMO, p=0.001).

CONCLUSIONS

Advances in ECMO technology, particularly VV ECMO, have greatly improved the ability to support patients with severe PGD after lung transplantation. VV ECMO is an important tool in the armamentarium of any lung transplant program to optimize patient outcomes; however, strategies to improve lung allograft function in patients experiencing severe PGD are still needed.

Extracorporeal membrane oxygenation as a bridge to lung transplant: midterm outcomes

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is used occasionally as a bridge to lung transplantation. The impact on mid-term survival is unknown. We analyzed outcomes after lung transplant over a 19-year period in patients who received ECMO support.

METHODS

From March 1991 to October 2010, 1,305 lung transplants were performed at our institution. Seventeen patients (1.3%) were supported with ECMO before lung transplant. Diagnoses included retransplantation (n = 6), pulmonary fibrosis (n = 6), cystic fibrosis (n = 4), and chronic obstructive pulmonary disease (n = 1). Fifteen patients underwent double lung transplant, one patient had single left lung transplant and one patient had a heart-lung transplant. Venovenous and venoarterial ECMO were implanted in eight and nine cases, respectively. Median duration of support was 3.2 days (range, 1 to 49 days). Mean patient follow-up was 2.3 years.

RESULTS

Thirty-day, 1-year, and 3-year survivals were 81%, 74%, and 65%, respectively, for the supported patients and 93%, 78%, and 62% in the control group (p = 0.56). Two-year survival was not affected by ECMO type, with survival of five out of nine patients supported by venoarterial ECMO vs seven out of eight patients supported by venovenous ECMO (p = 0.17). At 1- year follow-up, allograft function for the ECMO-supported patients did not differ from the control group (forced expiratory volume in one second, 2.35 L vs 2.09 L, p = 0.39) (forced vital capacity, 3.06 L vs 2.71 L, p = 0.34).

CONCLUSIONS

Extracorporeal membrane oxygenation as a bridge to lung transplantation is associated with higher perioperative mortality but acceptable mid-term survival in carefully selected patients. Late allograft function did not differ in patients who received ECMO support before lung transplant from those who did not receive ECMO.

Primary graft dysfunction

Primary graft dysfunction (PGD) is the most important cause of early morbidity and mortality following lung transplantation. PGD affects up to 25% of all lung transplant procedures and currently has no proven preventive therapy. Lung transplant recipients who recover from PGD may have impaired long-term function and an increased risk of bronchiolitis obliterans syndrome. This article aims to provide a state-of-the-art review of PGD epidemiology, outcomes, and risk factors, and to summarize current efforts at biomarker development and novel strategies for prevention and treatment.

Extracorporeal life support as a bridge to lung transplantation

Patients who are excellent candidates for lung transplantation often die on the waiting list because they are too sick to survive until an organ becomes available. Improvements in lung transplant outcomes, patient selection, and artificial lung device technologies have made it possible to bridge these patients to successful life-saving transplantation. Extracorporeal life support (ECLS) should be tailored to minimize morbidity and provide the appropriate mode and level of cardiopulmonary support for each patient's physiologic requirements. Novel device refinements and further development of ECLS in an ambulatory and simplified manner will help maintain these patients in better condition until transplantation.

Prognostic factors in lung transplantation: the Santa Casa de Porto Alegre experience

BACKGROUND

Lung transplantation (LT) has been established as a current therapy for selected patients with end-stage lung disease. Different prognostic factors have been reported by transplant centers. The objective of this study is to report our recent results with LT and to search for prognostic factors.

METHODS

We performed a retrospective analysis of 130 patients who underwent LT at our institution from January 2004 to July 2009. Donor, recipient, intraoperative, and postoperative variables were collected.

RESULTS

The mean age was 53.14 years (ranging from 8 to 72 years) and 80 (61.5%) were male. The main causes of end-stage respiratory disease were pulmonary fibrosis 53 (40.7%) and chronic obstructive pulmonary disease 52 (40%). The actuarial 1-year survival was 67.7%. Variables correlated with survival were age (P=0.004), distance in the 6-min walk test (P=0.007), coronary heart disease (P=0.001), cardiopulmonary bypass (P=0.02), intraoperative transfusion of red blood cells (P=0.016), increasing central venous pressure at 24th postoperative hour (P=0.001), increasing pulmonary capillary wedge pressure at 24th postoperative hour (P=0.01); length of intubation (P<0.01), reintubation (P=0.001), length of intensive care unit stay (P<0.001), abdominal complication (P=0.003), acute renal failure requiring dialysis (P<0.001), native lung hyperinflation (P=0.02), and acute rejection in the first month (P=0.03). In multivariate analysis, only dialysis (P=0.004, hazards ratio [HR] 2.68), length of intubation (P=0.004, HR 1.002 for each hour), and reintubation (P=0.003, HR 2.88) proved to be independent predictors.

CONCLUSION

Analysis of variables in our cohort highlighted dialysis, longer mechanical ventilation requirement, and reintubation as independent prognostic factors in LT.

Extra corporal membrane oxygenation in general thoracic surgery: a new single veno-venous cannulation

Extracorporeal membrane oxygenation (ECMO) is used in severe respiratory failure to maintain adequate gas exchange. So far, this technique has not been commonly used in general thoracic surgery. We present a case using ECMO for peri-operative airway management for pulmonary resection, using a novel single-site, internal jugular, veno-venous ECMO cannula.

Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults

PURPOSE

Historically, venovenous extracorporeal membrane oxygenation has required dual cannulation. A single-venous cannulation strategy may facilitate implantation and patient mobilization. Here we present our early experience with a single cannulation technique.

DESCRIPTION

Review of venovenous extracorporeal membrane oxygenation support using internal jugular vein insertion of the Avalon elite bicaval dual lumen catheter (Avalon Laboratories, Rancho Dominguez, CA) in 11 consecutive patients with severe respiratory failure.

EVALUATION

Adequate oxygenation was obtained in all patients: 115 mm Hg PaO(2) (median), 53 to 401 mm Hg (range). Median time of support was 78 hours (range, 3 to 267 hours). No mortality was directly related to the cannulation strategy. There were three nonfatal cannulation-related events. Two patients had proximal cannula displacement requiring repositioning. One patient suffered an acute thrombosis of the cannula.

CONCLUSIONS

Our series supports single-venous cannulation in venovenous extracorporeal membrane oxygenation as a promising technique. It may be an excellent alternative to current cannulation strategies in patients requiring prolonged support and specifically for those considered for a bridge-to-lung transplantation.

[Early postoperative management and immunosuppressive treatment following lung transplantation]

Lung transplantation is now considered a valid option in the management of end-stage respiratory failure. The postoperative period remains a key stage that will influence the average long-term prognosis of the patients. Primary graft failure, postoperative bleeding, infection, acute rejection and complications linked to the surgery, and to vascular or bronchial anastomoses, are risk factors for mortality and morbidity. These must be taken care of quickly via collaboration with the surgical team. The immunosuppressive treatment essential for tolerance induction with regard to the transplanted organ will be introduced during the intraoperative period and continued for life. The combination of a calcineurin inhibitor, an antiproliferative agent and corticosteroids remains the conventional procedure. The role of new molecules as mTor inhibitors remains to be determined.