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

Anesthetic management of the patient with extracorporeal membrane oxygenator support

The use of short-term mechanical circulatory support in the form of extracorporeal membrane oxygenation (ECMO) in adult patients has increased over the last decade. Cardiothoracic anesthesiologists may care for these patients during ECMO placement and for procedures while ECMO support is in place. An understanding of ECMO capabilities, indications, and complications is essential to the anesthesiologist caring for these patients. Below we review the anesthetic considerations for the implantation of ECMO and concerns when caring for patients on ECMO.

Twenty-years of lung transplantation in Taiwan: Effects of cumulative institutional experience on early outcomes

BACKGROUND/PURPOSE

Lung transplantation in Taiwan began in 1991, but the experience was limited and diverse in the early years. We examined the cumulative institutional experience of the largest lung transplant cohort in Taiwan.

METHODS

A retrospective review of lung transplantations performed at a single institution from December 1995 through August 2016 was conducted. For comparative purposes, the cohort was divided into halves, with an early group (undergoing lung transplantation in the first decade) vs a late group (undergoing lung transplantation in the second decade). Standardized donor selection, organ procurement, and preservation protocols for brain-dead donors were applied. The outcomes measured were 30-day mortality and actuarial survival using the Kaplan-Meier method.

RESULTS

The cohort included 50 recipients in the early group and 42 recipients in the late group. Compared with the early group, recipients in the late group were significantly older (38.8 ± 11.6 vs 44.8 ± 13.4 years, p = 0.024) and more of them required mechanical ventilation before transplant (26.0% vs 66.7%, p < 0.001). There were more female donors (12.0% vs 33.3%, p = 0.021) and gender-matched donors (34.0% vs 61.9%, p = 0.012) in the late group. A total of 87 recipients (94.6%) had cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) support during transplant, and CPB was used significantly less in the late group. Graft procedures (14.0% vs 47.6%, p < 0.001), delayed chest closure (0% vs 21.4%, p < 0.001), and early tracheostomy (24.0% vs 52.4%, p = 0.005) were performed more in the late group. The durations of hospital and ICU stays were comparable in both groups, but the 30-day mortality was significantly lower in the late group (30.0% vs 2.4%, p = 0.001).

CONCLUSION

Although the results were undesirable in the first decade of the transplant program, the cumulative institutional experience led to significantly improved outcomes in the second decade of the transplant program.

Extracorporeal Life Support in Lung Transplantation

Extracorporeal life support in lung transplantation has been associated with poor posttransplant outcomes. However, recent advances have resulted in more favorable posttransplant outcomes. The increased use of this technology must be weighed against the risks inherent in its use, especially when complications arising in extracorporeal membrane oxygenation (ECMO)-dependent patients result in loss of transplant candidacy, leaving them with no viable alternative for long-term support. Existing and emerging data support the judicious use of this technology in carefully selected patients at high-volume transplant and ECMO centers that prioritize minimization of sedation, avoidance of endotracheal intubation, and early mobilization.

Extracorporeal membrane oxygenation versus cardiopulmonary bypass during lung transplantation: a meta-analysis

BACKGROUND

We reviewed the available literature on patients undergoing lung transplantation supported by cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO).

METHODS

A systematic literature search was performed in three databases, in accordance with the PRISMA guidelines. Meta-analyses were used to compare the outcomes of ECMO and CPB procedures.

RESULTS

Seven observational studies met the inclusion criteria incorporating 785 patients. ECMO support showed lower rate of primary graft dysfunction, bleeding, renal failure requiring dialysis, tracheostomy, intraoperative transfusions, intubation time, and hospital stay. Total support time was greater for the ECMO-supported group. No difference was reported between operative and ischemic time.

CONCLUSIONS

The present study indicates that the intraoperative use of ECMO is associated with increased efficacy and safety, regarding short-term outcomes, compared to CPB. Well-designed, randomized studies, comparing ECMO to CPB, are necessary to assess their clinical outcomes further.

Anesthesia for Lung Transplantation

Perioperative management of patients undergoing lung transplantation is challenging and requires constant communication among the surgical, anesthesia, perfusion, and nursing teams. Although all aspects of anesthetic management are important, certain intraoperative strategies (mechanical ventilation, fluid management, extracorporeal mechanical support deployment) have tremendous impact on the subsequent evolution of the lung transplant recipient, especially with respect to allograft function, and should be carefully considered. This review highlights some of the intraoperative anesthetic challenges and opportunities during lung transplantation.

Extra corporeal membrane oxygenation support: ethical dilemmas

The vast expansion of patients treated with of extra corporeal membrane oxygenation (ECMO) emerge novel ethical questions about the use of this new technology. In regard the indications, duration of support and timing of withdrawal of support, these questions sometimes create disagreement among surrogates, between health care team and surrogates, and even disagreement among health care team, these disagreements occurs because of the extreme emergency of support initiation, the ambiguity of the outcome as well as lack of clarity on the intended treatment direction, whether it is ineffective, bridge to recovery or bridge to lifetime mechanical support or transplant. In this article we discuss these questions through patients' scenarios.

Combined Bilateral Lung Transplantation and Off-Pump Coronary Artery Bypass

Coronary artery disease has historically been a contraindication to lung transplantation. We report a successful combined bilateral lung transplantation and off-pump coronary artery bypass in a 62-year-old man. The patient had a progressive decline in lung function due to idiopathic pulmonary fibrosis and a history of severe occlusive coronary artery disease.

Clinical equivalency of cardiopulmonary bypass and extracorporeal membrane oxygenation support for pediatric tracheal reconstruction

OBJECTIVE

Pediatric surgery for congenital tracheal stenosis continues to be a therapeutic challenge, and it often requires cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) for intra-operative extracorporeal cardiorespiratory support. The purpose of this study was to compare the peri-operative outcomes of CPB with ECMO in pediatric tracheal reconstruction.

METHODS

Forty-three consecutive patients who underwent tracheal reconstruction without intra-cardiac repair for congenital tracheal stenosis at Kobe Children's Hospital between January 2000 and August 2012 were enrolled in this retrospective study. They were divided into two groups according to intra-operative extracorporeal cardiopulmonary support [CPB (n = 17) or ECMO (n = 26)]. Peri-operative variables were compared between the two groups.

RESULTS

The CPB and ECMO groups had similar patient and operative characteristics. However, the CPB group required larger priming volume and higher doses of total heparin injection. Although the ECMO group exhibited less peri-operative bleeding and lower red blood cell requirement, there were no statistically significant differences between the two groups. Compared to the ECMO group, patients in the CPB group had significantly less positive fluid balance during surgery and in the first 24 h after surgery, and exhibited a trend towards higher ratios of PO₂ to the fraction of inspired oxygen and lower PCO₂ at the time of ICU admission and on post-operative day 1.

CONCLUSIONS

Pediatric tracheal reconstruction should be performed with intra-operative CPB or ECMO, after considering the advantages of utilizing each extracorporeal cardiorespiratory support type according to the patient's specific condition and situation.

Transition to routine use of venoarterial extracorporeal oxygenation during lung transplantation could improve early outcomes

BACKGROUND

The study objective was to compare the outcomes of intraoperative routine use of venoarterial (VA) extracorporeal membrane oxygenation (ECMO) versus selective use of cardiopulmonary bypass (CPB).

METHODS

Between January 2010 and February 2013, 41 lung transplantations (LTx) were performed, and CPB was used as a primary cardiopulmonary support modality by selective basis (group A). Between March 2013 and December 2014, 41 LTx were performed, and ECMO was used routinely (group B). The two groups were compared retrospectively.

RESULTS

The operative time was significantly longer in group A (group A, 458 min; group B, 420 min; P=0.041). Postoperatively, patients in group B had less fresh frozen plasma (FFP) transfusion (P=0.030). Complications were not different between the two groups. The 30- and 90-day survival rates were better in group B (30-day survival: group A, 75.6%; group B, 95.1%, P=0.012; 90-day survival: group A, 68.3%; group B, 87.8%, P=0.033). The 1-year survival showed better trends in group B, but it was not significant. Forced vital capacity (FVC) at 1, 3, and 6 months after LTx was better in group B than in group A (1 month: group A, 43.8%; group B, 52.9%, P=0.043; 3 months: group A, 45.5%; group B, 59.0%, P=0.005; 6 months: group A, 51.5%; group B, 65.2%, P=0.020). Forced expiratory volume in 1 second (FEV1) at 3 months after LTx was better in patients in group B than that in patient in group A (group A, 53.3%; group B, 67.5%, P=0.017).

CONCLUSIONS

Routine use of ECMO during LTx could improve early outcome and postoperative lung function without increased extracorporeal-related complication such as vascular and neurologic complications.

The Outcome of Patients Requiring Multiple Extracorporeal Membrane Oxygenation: How Many Runs of ECMO is Reasonable?

Background

Extracorporeal membrane oxygenation (ECMO) has been proven effective in life support for patients with refractory cardiopulmonary failure. Deteriorating patients who have removed their first ECMO support and required second or more courses of ECMO support have rarely been discussed.

Methods and Results

All the records of the patients who experienced at least 2 courses of ECMO during single admission were retrieved. Survival was defined as survival to discharge. Demographic data and clinical information were compared between survival and nonsurvival groups. There were 86 patients who received at least 2 courses of ECMO in the 20-year database, and 27 (31.3%) were <18 years old. Of them, 87.3% received 2 runs of ECMO, 10.4% 3 runs, and 2.3% 4 runs. Overall survival rate was 30.2%. The survival rate for patients with 2 runs of ECMO was 33.3% (25 out of 75), 11.1% (1 out of 9) for 3 runs, and 0% (0 out of 2) for 4 runs. Multivariate analysis revealed that only ARF with hemodialysis was the independent risk factor.

Conclusions

The decision to perform repeated ECMO implantation is a complex and difficult process. Despite the arguments debating the consumption of resources and increased complications, there are still nearly 1 out of 3 patients who will survive to discharge. More than 2 courses of ECMO may be carefully considered for further rescue.

New horizons of non-emergent use of extracorporeal membranous oxygenator support

The expansion of the extra corporeal membrane oxygenation (ECMO) use and its indication is strikingly increased in the past few years. ECMO use expanded to lung transplantation, difficult general thoracic resections, transcatheter aortic valve replacement (TAVR) and LVAD implantation. Here we will discuss the indications and the outcomes of non-emergent use of ECMO.

Cardiopulmonary Bypass and Extracorporeal Life Support for Emergent Intraoperative Thoracic Situations

Intraoperative thoracic surgical catastrophes may require extracorporeal circulation modes to support the patient while the appropriate repair is made. Teamwork is key and, given the evidence supporting better performance with the use of simulation and surgical-crisis checklists, their use should be encouraged. Anticipation is another important factor because the results of intrathoracic malignancy resection are clearly superior in the setting of planned cardiopulmonary support. In addition, familiarity with the different modes of support that are currently available can direct the decision-making process toward the best option to facilitate resolution of the intraoperative catastrophe with the least related morbidity.

Five-year experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: Indications and midterm results

BACKGROUND

Since April 2010, extracorporeal membrane oxygenation (ECMO) has replaced cardiopulmonary bypass for intraoperative support during lung transplantation at our institution. The aim of this study was to present our 5-year experience with this technique.

METHODS

Records of patients who underwent transplantation between April 2010 and January 2015 were retrospectively reviewed. Patients who underwent transplantation without ECMO formed Group A. Patients in whom the indication for ECMO support was set a priori before the beginning of the operation formed Group B. The remaining patients in whom the indication for ECMO support was set during transplantation formed Group C.

RESULTS

Among 595 patients, 425 (71%) patients (Group A) did not require intraoperative ECMO; the remaining 170 (29%) patients did. Among these patients, 95 (56%) patients formed Group B, and the remaining 75 (44%) patients comprised Group C. Pulmonary fibrosis and pre-operative dilated or hypertrophied right ventricle emerged as risk factors for the indication of non-a priori intraoperative ECMO. Patients in Groups B and C showed a higher pre-operative risk profile and higher prevalence of post-operative complications than patients in Group A. Overall survival at 1 year was 93%, 83%, and 82% and at 4 years was 73%, 68%, and 69% in Groups A, B, and C (p = 0.11). The intraoperative use of ECMO did not emerge as a risk factor for in-hospital mortality or mortality after hospital discharge.

CONCLUSIONS

Intraoperative ECMO filled the gap between pre-operative and post-operative ECMO in lung transplantation. Although complications and in-hospital mortality were higher in patients who received ECMO, survival was similar among patients who underwent transplantation with or without ECMO.

Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology

Extra Corporeal Membrane Oxygenation (ECMO) indications and usage has strikingly progressed over the last 20 years; it has become essential tool in the care of adults and children with severe cardiac and pulmonary dysfunction refractory to conventional management. In this article we will provide a review of ECMO development, clinical indications, patients' management, options and cannulations techniques, complications, outcomes, and the appropriate strategy of organ management while on ECMO.

MECHANICAL VENTILATION FOR THE LUNG TRANSPLANT RECIPIENT

Mechanical ventilation (MV) is an important aspect in the intraoperative and early postoperative management of lung transplant (LTx)-recipients. There are no randomized-controlled trials of LTx-recipient MV strategies; however there are LTx center experiences and international survey studies reported. The main early complication of LTx is primary graft dysfunction (PGD), which is similar to the adult respiratory distress syndrome (ARDS). We aim to summarize information pertinent to LTx-MV, as well as PGD, ARDS, and intraoperative MV and to synthesize these available data into recommendations. Based on the available evidence, we recommend lung-protective MV with low-tidal-volumes (≤6 mL/kg predicted body weight [PBW]) and positive end-expiratory pressure for the LTx-recipient. In our opinion, the MV strategy should be based on donor characteristics (donor PBW as a parameter of actual allograft size), rather than based on recipient characteristics; however this donor-characteristics-based protective MV is based on indirect evidence and requires validation in prospective clinical studies.