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Balasubramanian P, Ghimire M, Pattnaik H, Saunders H, Franco PM, Sanghavi D, Patel NM, Baig H, Bhattacharyya A, Chaudhary S, Guru PK. Clinical Outcomes With Extracorporeal Membrane Oxygenation for Interstitial Lung Disease: Systematic Review and Meta-Analysis. ASAIO J 2024:00002480-990000000-00494. [PMID: 38810214 DOI: 10.1097/mat.0000000000002231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
The evidence on indications, outcomes, and complications with the use of extracorporeal membrane oxygenation (ECMO) in the setting of interstitial lung disease (ILD) is limited in the existing literature. We performed a systematic review and meta-analysis for the use of ECMO in the setting of ILD to study the prognostic factors associated with in-hospital mortality. Eighteen unique studies with a total of 1,356 patients on ECMO for ILD were identified out of which 76.5% were on ECMO as a bridge to transplant (BTT) and the rest as a bridge to recovery (BTR). The overall in-hospital mortality was 45.76%, with 71.3% and 37.8% for BTR and BTT, respectively. Among the various prognostic factors, mortality was lower with younger age (mean difference = 3.15, 95% confidence interval [CI] = 0.82-5.49), use of awake veno-arterial (VA)-ECMO compared to veno-venous (VV)-ECMO (unadjusted odds ratio [OR] = 0.22, 95% CI = 0.13-0.37) in the overall cohort. In the setting of BTT, the use of VA-ECMO had a decreased hazard ratio (HR) compared to VV-ECMO (adjusted HR = 0.34, 95% CI = 0.15-0.81, p = 0.015). The findings of our meta-analysis are critical but are derived from retrospective studies with small sample sizes and thus are of low to very low-GRADE certainty.
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Affiliation(s)
| | - Manoj Ghimire
- Department of Internal Medicine, Bronx Healthcare, Bronx, New York
| | | | - Hollie Saunders
- From the Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Neal M Patel
- From the Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Hassan Baig
- From the Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
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2
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Zhu Y, Zeng F, Lan MJ, Liang JSY, Cai LY, Gu PP, Guo LY. Prognostic factors in lung transplantation after extracorporeal membrane oxygenation bridging therapy: a systematic review and meta-analysis. J Thorac Dis 2024; 16:2216-2224. [PMID: 38738255 PMCID: PMC11087642 DOI: 10.21037/jtd-23-1709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/08/2024] [Indexed: 05/14/2024]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has recently emerged as a critical support system for lung function in patients awaiting lung transplantation. This meta-analysis investigates the prognostic factors of lung transplantation following ECMO bridging therapy. Methods A comprehensive search was conducted in PubMed, Cochrane Library, Embase, CINAHL, Web of Science, Scopus, and ProQuest databases from inception to August 11, 2023. Included were cohort or case-control studies focusing on prognostic factors of lung transplantation with ECMO bridging therapy. Data extraction was performed independently, and study quality was assessed. A meta-analysis was carried out using RevMan 5.4 and Stata17.0 software to aggregate mortality rates and pertinent prognostic factors of ECMO as a bridge to lung transplantation. Results The search identified eight trials encompassing 1,086 participants. The prognosis of patients undergoing lung transplantation with ECMO bridging was significantly associated with several factors: prolonged ECMO support [odds ratio 1.07, 95% confidence interval (CI): 1.02-1.12, I2=77%], deterioration in liver and kidney function (odds ratio 3.62, 95% CI: 2.37-5.54, I2=0%), and complications during ECMO (odds ratio 2.24, 95% CI: 1.45-3.44, I2=5%). Conclusions Prolonged ECMO support, declining liver and kidney functions, and complications during ECMO are vital prognostic factors in lung transplantation following ECMO bridging therapy.
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Affiliation(s)
- Yan Zhu
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Fei Zeng
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Mei-Juan Lan
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jiang-Shu-Yuan Liang
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ling-Yun Cai
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Pei-Pei Gu
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lu-Yao Guo
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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3
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Girgis RE, Manandhar‐Shrestha NK, Krishnan S, Murphy ET, Loyaga‐Rendon R. Predictors of early mortality after lung transplantation for idiopathic pulmonary arterial hypertension. Pulm Circ 2024; 14:e12371. [PMID: 38646412 PMCID: PMC11027072 DOI: 10.1002/pul2.12371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 04/23/2024] Open
Abstract
Lung transplantation remains an important therapeutic option for idiopathic pulmonary arterial hypertension (IPAH), yet short-term survival is the poorest among the major diagnostic categories. We sought to develop a prediction model for 90-day mortality using the United Network for Organ Sharing database for adults with IPAH transplanted between 2005 and 2021. Variables with a p value ≤ 0.1 on univariate testing were included in multivariable analysis to derive the best subset model. The cohort comprised 693 subjects, of whom 71 died (10.2%) within 90 days of transplant. Significant independent predictors of early mortality were: extracorporeal circulatory support and/or mechanical ventilation at transplant (OR: 3; CI: 1.4-5), pulmonary artery diastolic pressure (OR: 1.3 per 10 mmHg; CI: 1.07-1.56), forced expiratory volume in the first second percent predicted (OR: 0.8 per 10%; CI: 0.7-0.94), recipient total bilirubin >2 mg/dL (OR: 3; CI: 1.4-7.2) and ischemic time >6 h (OR: 1.7, CI: 1.01-2.86). The predictive model was able to distinguish 25% of the cohort with a mortality of ≥20% from 49% with a mortality of ≤5%. We conclude that recipient variables associated with increasing severity of pulmonary vascular disease, including pretransplant advanced life support, and prolonged ischemic time are important risk factors for 90-day mortality after lung transplant for IPAH.
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Affiliation(s)
- Reda E. Girgis
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - Nabin K. Manandhar‐Shrestha
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - Sheila Krishnan
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - Edward T. Murphy
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - Renzo Loyaga‐Rendon
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
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4
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Zhou AL, Jenkins RT, Ruck JM, Shou BL, Larson EL, Casillan AJ, Ha JS, Merlo CA, Bush EL. Outcomes of Recipients Aged 65 Years and Older Bridged to Lung Transplant With Extracorporeal Membrane Oxygenation. ASAIO J 2024; 70:230-238. [PMID: 37939695 PMCID: PMC10922625 DOI: 10.1097/mat.0000000000002092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (BTT) has been used for critically ill candidates with excellent outcomes, but data on this strategy in older recipients remain limited. We compared outcomes of no BTT, mechanical ventilation (MV)-only BTT, and ECMO BTT in recipients of greater than or equal to 65 years. Lung-only recipients of greater than or equal to 65 years in the United Network for Organ Sharing database between 2008 and 2022 were included and stratified by bridging strategy. Of the 9,936 transplants included, 226 (2.3%) were MV-only BTT and 159 (1.6%) were ECMO BTT. Extracorporeal membrane oxygenation BTT recipients were more likely to have restrictive disease pathology, had higher median lung allocation score, and spent fewer days on the waitlist (all p < 0.001). Compared to no-BTT recipients, ECMO BTT recipients were more likely to be intubated or on ECMO at 72 hours posttransplant and had longer hospital lengths of stay (all p < 0.001). Extracorporeal membrane oxygenation BTT recipients had increased risk of 3 years mortality compared to both no-BTT (adjusted hazard ratio [aHR] = 1.48 [95% confidence interval {CI}: 1.14-1.91], p = 0.003) and MV-only recipients (aHR = 1.50 [95% CI: 1.08-2.07], p = 0.02). Overall, we found that ECMO BTT in older recipients is associated with inferior posttransplant outcomes compared to MV-only or no BTT, but over half of recipients remained alive at 3 years posttransplant.
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Affiliation(s)
- Alice L. Zhou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Reed T. Jenkins
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Jessica M. Ruck
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Benjamin L. Shou
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Emily L. Larson
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Alfred J. Casillan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Jinny S. Ha
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Hospital
| | - Errol L. Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins Hospital
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5
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Trivedi JR, Endo T, Sharma A, Fox MP, Slaughter MS, van Berkel VH. Ambulatory Extracorporeal Membrane Oxygenation Use in Patients Listed for Lung Transplant. ASAIO J 2024:00002480-990000000-00406. [PMID: 38300884 DOI: 10.1097/mat.0000000000002154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
There has been an increase in the use of extracorporeal membrane oxygenation (ECMO) to bridge critically ill patients to lung transplant (LTX). This study evaluates how ambulatory status on ECMO affected waitlist and post-LTX outcomes. The United Network of Organ Sharing (UNOS) database was queried for patients aged of greater than or equal to 18 years and between 2016 and 2021 to identify pre-LTX patients supported by ECMO. The patients were classified in venous-arterial (VA) ECMO and veno-venous (VV) ECMO cohorts and further classified as ambulatory (AMB) and non-AMB (nAMB). Each cohort was controlled against the non-ECMO patients. Univariate statistical tests, as well as Kaplan-Meier survival curves, were used for analysis. The 90 day waitlist survival was the highest among the non-ECMO group (96%), but both AMB VV and VA groups had superior survival compared to the nAMB group (85% vs. 75%, 78% vs. 65%, p < 0.01). After adjusting for the median lung allocation score (LAS) (88) in the VV ECMO group, the waitlist survival was superior in the AMB VV ECMO compared to those not on ECMO (86% vs. 78%, p > 0.01). The 1 year post-LTX survival between non-ECMO and AMB VV ECMO was comparable (88% vs. 88%, p = 0.66). Ambulating patients or use of physical therapy while on ECMO can help improve lung transplant outcomes.
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Affiliation(s)
- Jaimin R Trivedi
- From the Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
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6
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Fritz AV, Teixeira MT, Patel SJ, Burtoft M, Martin AK. Update in lung transplantation: anesthetic considerations. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:389. [PMID: 37970597 PMCID: PMC10632582 DOI: 10.21037/atm-22-4602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 06/16/2023] [Indexed: 11/17/2023]
Abstract
The field of lung transplantation (LTx) has expanded rapidly since its inception in the early 1960s with the work of James Hardy and colleagues at the University of Mississippi from the work of local single specialty physicians into an international multidisciplinary specialty. Advancements throughout the next several decades have led to the completion of over 70,000 lung transplants worldwide. The unique challenges presented by patients with end-stage lung disease have both evolved and remained consistent since then, yet these challenges are being answered with major improvements and advancements in perioperative care in the 21st century. The current practice of LTx medicine is fundamentally multidisciplinary, and members of the LTx team includes surgeons, physicians, and allied health staff. The integration of anesthesiologists into the LTx team as well as the multidisciplinary nature of LTx necessitates anesthetic considerations to be closely incorporated into emerging surgical, medical, and systems techniques for patient care. This review discusses a host of emerging strategies across the spectrum of LTx, including efforts to expand the donor pool, utilization of perioperative extracorporeal life support, perioperative echocardiography, and anesthetic techniques to mitigate primary graft dysfunction that have all contributed to improved long term outcomes in LTx patients.
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Affiliation(s)
- Ashley V. Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Miguel T. Teixeira
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Saumil J. Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa Burtoft
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
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7
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Lehr CJ, Schold JD, Arrigain S, Valapour M. New OPTN/UNOS data demonstrates higher than previously reported waitlist mortality for lung transplant candidates supported with ECMO. J Heart Lung Transplant 2023; 42:1399-1407. [PMID: 37150472 PMCID: PMC10524253 DOI: 10.1016/j.healun.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 04/05/2023] [Accepted: 04/30/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) is not currently incorporated into US allocation models due to the historical lack of complete data in the national US registry which changed in 2016 to include ECMO at the time of waitlist removal and more granular timing and configuration data. METHODS We studied adult lung transplant candidates from May 1, 2016 to June 1, 2020 with data abstracted from multiple sources in the US Scientific Registry of Transplant Recipients. Waitlist analyses included cumulative incidence functions and Cox proportional hazards models considering ECMO as a time-dependent variable. Post-transplant analyses included Kaplan Meier, Cox proportional hazards models, and observed to expected survival ratios. RESULTS A total of 867 candidates were on ECMO prior to transplant; 247 were identified using new sources of data. Candidates on ECMO had a 23.9 increased adjusted likelihood of waitlist removal for being too sick or death, but only a 4.08 increased adjusted likelihood of transplant. Candidates bridged with ECMO who underwent lung transplant (N = 587) experienced an increased overall hazard of post-transplant mortality with veno-arterial and veno-venous configurations conferring hazard ratio (HR) = 1.67 (95% CI, 1.16, 2.40), HR = 1.45 (95% CI, 1.15, 1.82), respectively. CONCLUSIONS We identified an additional 28.5% of candidates bridged with ECMO prior to transplant using new data. This study of the newly identified full cohort of ECMO candidates demonstrates higher utilization of ECMO as well as an underestimation of waitlist mortality risk factors that should inform strategies to provide timely access to transplants for this population.
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Affiliation(s)
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Susana Arrigain
- Department of Quantitative Health Sciences, Cleveland Clinic
| | - Maryam Valapour
- Respiratory Institute, Cleveland Clinic. https://twitter.com/@MValapour
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8
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Koh W, Zang H, Ollberding NJ, Ziady A, Hayes D. Extracorporeal membrane oxygenation bridge to pediatric lung transplantation: Modern era analysis. Pediatr Transplant 2023; 27:e14570. [PMID: 37424517 PMCID: PMC10530187 DOI: 10.1111/petr.14570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/24/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Survival outcomes of children on extracorporeal membrane oxygenation (ECMO) at time of lung transplant (LTx) remain unclear. METHODS Pediatric first-time LTx recipients transplanted between January 2000 and December 2020 were identified in the United Network for Organ Sharing Registry to compare post-transplant survival according to ECMO support at time of transplant. For a comprehensive analysis of the data, univariate analysis, multivariable Cox regression, and propensity score matching were performed. RESULTS During the study period, 954 children under 18 years of age underwent LTx with 40 patients on ECMO. We did not identify a post-LTx survival difference between patients receiving ECMO when compared to those that did not. A multivariable Cox regression model (Hazard ratio = 0.83; 95% confidence interval: 0.47, 1.45; p = .51) did not demonstrate an increased risk for death post-LTx. Lastly, a propensity score matching analysis, retaining 33 ECMO and 33 non-ECMO patients, further confirmed no post-LTx survival difference comparing ECMO to no ECMO cohorts (Hazard ratio = 0.98; 95% confidence interval: 0.48, 2.00; p = .96). CONCLUSIONS In this contemporary cohort of children, the use of ECMO at the time of LTx did not negatively impact post-transplant survival.
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Affiliation(s)
- Wonshill Koh
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Huaiyu Zang
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Nicholas J. Ollberding
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Assem Ziady
- Dvision of Bone Marrow Transplant, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Don Hayes
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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9
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Quinn RE, Riedl R, Rycus PT, Vogel TP, Silva-Carmona M, Anders MM, O'Neil ER. Extracorporeal Membrane Oxygenation Support for Interstitial Lung Disease in Idiopathic Inflammatory Myopathies: An ELSO Registry Analysis. ASAIO J 2023; 69:e96-e99. [PMID: 36228185 DOI: 10.1097/mat.0000000000001798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Rachel E Quinn
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Ruth Riedl
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Peter T Rycus
- The Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Tiphanie P Vogel
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Manuel Silva-Carmona
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Marc M Anders
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Erika R O'Neil
- From the Department of Pediatrics, Baylor College of Medicine, Houston, Texas.,Department of Pediatrics, Texas Children's Hospital, Houston, Texas
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10
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Courtwright AM, Devarajan J, Fritz AV, Martin AK, Wilkey B, Subramani S, Cassara CM, Tawil JN, Miltiades AN, Boisen ML, Bottiger BA, Pollak A, Gelzinis TA. Cardiothoracic Transplant Anesthesia: Selected Highlights: Part I-Lung Transplantation. J Cardiothorac Vasc Anesth 2023; 37:884-903. [PMID: 36868904 DOI: 10.1053/j.jvca.2023.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Affiliation(s)
| | | | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Jacksonville, FL
| | | | - Barbara Wilkey
- Department of Anesthesiology, University of Colorado, Aurora, CO
| | - Sudhakar Subramani
- Department of Anesthesiology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Christopher M Cassara
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Justin N Tawil
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Andrea N Miltiades
- Department of Anesthesiology, Columbia University Medical Center, New York, NY
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brandi A Bottiger
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Angela Pollak
- Department of Anesthesiology, Duke University, Durham, NC
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11
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Hartwig M, van Berkel V, Bharat A, Cypel M, Date H, Erasmus M, Hoetzenecker K, Klepetko W, Kon Z, Kukreja J, Machuca T, McCurry K, Mercier O, Opitz I, Puri V, Van Raemdonck D. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation. J Thorac Cardiovasc Surg 2023; 165:301-326. [PMID: 36517135 DOI: 10.1016/j.jtcvs.2022.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation. METHODS The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement. RESULTS The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively. CONCLUSIONS Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.
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Affiliation(s)
- Matthew Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Durham, NC.
| | | | | | | | - Hiroshi Date
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Michiel Erasmus
- University Academic Center Groningen, Groningen, The Netherlands
| | | | | | | | - Jasleen Kukreja
- University of California San Francisco, San Francisco, Calif
| | - Tiago Machuca
- University of Florida College of Medicine, Gainesville, Fla
| | | | - Olaf Mercier
- Université Paris-Saclay and Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | | | - Varun Puri
- Washington University School of Medicine, St Louis, Mo
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12
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Experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: intraoperative indicators. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.7266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: Intraoperative extracorporeal membrane oxygenation (ECMO) is being used with increasing frequency in lung transplantation. However, the factors associated with the use of intraoperative ECMO in lung transplant patients are not yet conclusive. In this study, we aimed to determine the effective factors for providing intraoperative ECMO support in patients undergoing lung transplantation. In addition, we aimed to evaluate the effect of ECMO support on morbidity and mortality.
Methods: In this retrospective cohort study evaluating lung transplant patients, patients were divided into two groups: those who received intraoperative ECMO support and those who did not. Demographic data, the lung allocation score (LAS) and pulmonary arterial pressure (PAP), intraoperative data, postoperative complications, duration of mechanical ventilation (MV), length of stay (LOS) in intensive care and hospital, and mortality rates were recorded for both groups. Factors affecting entry to ECMO were analyzed by Multivariate Logistic Regression.
Results: In this period, 51.9% of 87 patients who underwent lung transplantation required intraoperative ECMO. The mean age, LAS, and PAP of the ECMO group were significantly higher than the non-ECMO group (P = 0.043, P = 0.007, and P = 0.007, respectively). In multivariate analysis, it was found that lower MAP averages were a predictive parameter in intraoperative ECMO requirements (OR: 1.091; CI: 1.009-1.179; P = 0.028). The ECMO group’s mechanical ventilation time and hospital mortality were significantly higher than the other group (P = 0.004 and P = 0.025, respectively).
Conclusion: Preoperative indicators of intraoperative ECMO support were determined as age, LAS, and PAP elevation. In addition, low MAP levels and high lactate levels were always determined as intraoperative indicators in lung transplantation until the transition to ECMO support.
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13
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Dallal-York J, Segalewitz T, Croft K, Colsky J, DiBiase L, Anderson A, Vasilopoulos T, Pelaez A, Shahmohammadi A, Pipkin M, Machuca TN, Plowman EK. Incidence, Risk Factors and Sequelae of Dysphagia Mediated Aspiration Following Lung Transplantation. J Heart Lung Transplant 2022; 41:1095-1103. [DOI: 10.1016/j.healun.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/11/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022] Open
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Clark JD, Baden HP, Berkman ER, Bourget E, Brogan TV, Di Gennaro JL, Doorenbos AZ, McMullan DM, Roberts JS, Turnbull JM, Wilfond BS, Lewis-Newby M. Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda. Front Pediatr 2022; 10:896232. [PMID: 35664885 PMCID: PMC9160718 DOI: 10.3389/fped.2022.896232] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.
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Affiliation(s)
- Jonna D Clark
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States.,Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States
| | - Harris P Baden
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Emily R Berkman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States.,Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States
| | - Erica Bourget
- Fred Hutchinson Cancer Research Center, University of Washington School of Medicine, Seattle, WA, United States
| | - Thomas V Brogan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Jane L Di Gennaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Ardith Z Doorenbos
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, United States.,Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois, Chicago, IL, United States
| | - D Michael McMullan
- Division of Pediatric Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, WA, United States
| | - Joan S Roberts
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Jessica M Turnbull
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States.,Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Benjamin S Wilfond
- Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States
| | - Mithya Lewis-Newby
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States.,Division of Pediatric Bioethics and Palliative Care, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States.,Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA, United States
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15
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Oh DK, Hong SB, Shim TS, Kim DK, Choi S, Lee GD, Kim W, Park SI. Effects of the duration of bridge to lung transplantation with extracorporeal membrane oxygenation. PLoS One 2021; 16:e0253520. [PMID: 34197496 PMCID: PMC8248733 DOI: 10.1371/journal.pone.0253520] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/08/2021] [Indexed: 11/26/2022] Open
Abstract
Background Although bridge to lung transplantation (BTT) with extracorporeal membrane oxygenation (ECMO) is increasingly performed, the impact of BTT and its duration on post-transplant outcomes are unclear. Methods We retrospectively reviewed medical records of adult patients who underwent lung or heart-lung transplantation in our institution between January 2008 and December 2018. Data were compared in patients who did (n = 41; BTT) and did not (n = 36; non-BTT) require pre-transplant ECMO support. Data were also compared in patients who underwent short-term (<14 days; n = 21; ST-BTT) and long-term (≥14 days; n = 20; LT-BTT) BTTs. Results Among 77 patients included, 51 (66.2%) were male and median age was 53 years. The median bridging time in the BTT group was 13 days (interquartile range [IQR], 7–19 days). Although simplified acute physiologic score II was significantly higher in the BTT group (median, 35; IQR, 31–49 in BTT group vs. median, 12; IQR, 7–19 in non-BTT group; p<0.001), 1-year (73.2% vs. 80.6%; p = 0.361) and 5-year (61.5% vs. 61.5%; p = 0.765) post-transplant survival rates were comparable in both groups. Comparison of ST- and LT-BTT subgroups showed that 1-year (90.5% vs. 55.0%; p = 0.009) and 5-year (73.0% vs. 48.1%; p = 0.030) post-transplant survival rates were significantly higher in ST-BTT group. In age and sex adjusted model, the LT-BTT was an independent risk factor for 1-year post-transplant mortality (hazard ratio, 3.019; 95% confidence interval, 1.119–8.146; p = 0.029), whereas the ST-BTT was not. Conclusions Despite the severe illness, the BTT group showed favorable post-transplantation outcomes, particularly those bridged for less than 14 days.
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Affiliation(s)
- Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae Sun Shim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Kwan Kim
- Department of Cardiothoracic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sehoon Choi
- Department of Cardiothoracic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Geun Dong Lee
- Department of Cardiothoracic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Won Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Il Park
- Department of Cardiothoracic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- * E-mail:
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