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von Dossow V, Hulde N, Starke H, Schramm R. How Would We Treat Our Own Cystic Fibrosis With Lung Transplantation? J Cardiothorac Vasc Anesth 2024; 38:626-634. [PMID: 38030425 DOI: 10.1053/j.jvca.2023.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/18/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
Lung transplantation is the only therapy for patients with end-stage lung disease. In advanced lung diseases such as cystic fibrosis (CF), life expectancy increases, and it is important to recognize extrapulmonary comorbidities. Cardiovascular involvement, including pulmonary hypertension, right-heart failure, and myocardial dysfunction, are manifest in the late stages of CF disease. Besides right-heart failure, left-heart dysfunction seems to be underestimated. Therefore, an optimal anesthesia and surgical management risk evaluation in this high-risk patient population is mandatory, especially concerning the perioperative use of mechanical circulatory support. The use of an index case of an older patient with the diagnosis of cystic fibrosis demonstrates the importance of early risk stratification and strategy planning in a multidisciplinary team approach to guarantee successful lung transplantation.
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Affiliation(s)
- Vera von Dossow
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
| | - Nikolai Hulde
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany.
| | - Henning Starke
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
| | - Rene Schramm
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
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Shou BL, Wilcox C, Florissi IS, Krishnan A, Kim BS, Keller SP, Whitman GJR, Uchino K, Bush EL, Cho SM. National Trends, Risk Factors, and Outcomes of Acute In-Hospital Stroke Following Lung Transplantation in the United States: Analysis of the United Network for Organ Sharing Registry. Chest 2023; 164:939-951. [PMID: 37054775 PMCID: PMC10567928 DOI: 10.1016/j.chest.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Lung transplantation (LTx) is the definitive treatment for end-stage lung failure. However, there have been no large, long-term studies on the impact of acute in-hospital stroke in this population. RESEARCH QUESTION What are the trends, risk factors, and outcomes of acute stroke in patients undergoing LTx in the United States? STUDY DESIGN AND METHODS We identified adult first-time isolated LTx recipients from the United Network for Organ Sharing database, which comprehensively captures every transplant in the United States, between May 2005 and December 2020. Stroke was defined as occurring at any time after LTx but prior to discharge. Multivariable logistic regression with stepwise feature elimination was used to identify risk factors for stroke. Freedom from death in patients with a stroke vs those without a stroke was evaluated with Kaplan-Meier analysis. Cox proportional hazards analysis was used to identify predictors of death at 24 months. RESULTS Of 28,564 patients (median age, 60 years; 60% male), 653 (2.3%) experienced an acute in-hospital stroke after LTx. Median follow-up was 1.2 (stroke) and 3.0 (non-stroke) years. Annual incidence of stroke increased (1.5% in 2005 to 2.4% in 2020; P for trend = .007), as did lung allocation score and utilization of post-LTx extracorporeal membrane oxygenation (P = .01 and P < .001, respectively). Compared with those without stroke, patients with stroke had lower survival at 1 month (84% vs 98%), 12 months (61% vs 88%), and 24 months (52% vs 80%) (log-rank test, P < .001 for all). In Cox analysis, acute stroke conferred a high hazard of mortality (hazard ratio, 3.01; 95% CI, 2.67-3.41). Post-LTx extracorporeal membrane oxygenation was the strongest risk factor for stroke (adjusted OR, 2.98; 95% CI, 2.19-4.06). INTERPRETATION Acute in-hospital stroke post-LTx has been increasing over time and is associated with markedly worse short- and long-term survival. As increasingly sicker patients undergo LTx as well as experience stroke, further research on stroke characteristics, prevention, and management strategies is warranted.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Christopher Wilcox
- Division of Neurosciences Critical Care, Johns Hopkins School of Medicine, Baltimore, MD
| | - Isabella S Florissi
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ken Uchino
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Errol L Bush
- Division of General Thoracic Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Sung-Min Cho
- Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, MD; Division of Neurosciences Critical Care, Johns Hopkins School of Medicine, Baltimore, MD.
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Subramaniam K, Loor G, Chan EG, Bottiger BA, Ius F, Hartwig MG, Daoud D, Zhang Q, Wei Q, Villavicencio-Theoduloz MA, Osho AA, Chandrashekaran S, Noguchi Machuca T, Van Raemdonck D, Neyrinck A, Toyoda Y, Kashem MA, Huddleston S, Ryssel NR, Sanchez PG. Intraoperative Red Blood Cell Transfusion and Primary Graft Dysfunction After Lung Transplantation. Transplantation 2023; 107:1573-1579. [PMID: 36959119 DOI: 10.1097/tp.0000000000004545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND In this international, multicenter study of patients undergoing lung transplantation (LT), we explored the association between the amount of intraoperative packed red blood cell (PRBC) transfusion and occurrence of primary graft dysfunction (PGD) and associated outcomes. METHODS The Extracorporeal Life Support in LT Registry includes data on LT recipients from 9 high-volume (>40 transplants/y) transplant centers (2 from Europe, 7 from the United States). Adult patients who underwent bilateral orthotopic lung transplant from January 2016 to January 2020 were included. The primary outcome of interest was the occurrence of grade 3 PGD in the first 72 h after LT. RESULTS We included 729 patients who underwent bilateral orthotopic lung transplant between January 2016 and November 2020. LT recipient population tertiles based on the amount of intraoperative PRBC transfusion (0, 1-4, and >4 units) were significantly different in terms of diagnosis, age, gender, body mass index, mean pulmonary artery pressure, lung allocation score, hemoglobin, prior chest surgery, preoperative hospitalization, and extracorporeal membrane oxygenation requirement. Inverse probability treatment weighting logistic regression showed that intraoperative PRBC transfusion of >4 units was significantly ( P < 0.001) associated with grade 3 PGD within 72 h (odds ratio [95% confidence interval], 2.2 [1.6-3.1]). Inverse probability treatment weighting analysis excluding patients with extracorporeal membrane oxygenation support produced similar findings (odds ratio [95% confidence interval], 2.4 [1.7-3.4], P < 0.001). CONCLUSIONS In this multicenter, international registry study of LT patients, intraoperative transfusion of >4 units of PRBCs was associated with an increased risk of grade 3 PGD within 72 h. Efforts to improve post-LT outcomes should include perioperative blood conservation measures.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Daoud Daoud
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Qianzi Zhang
- Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Qi Wei
- Department of Statistics, Phastar Inc, Durham, NC
| | | | - Asishana A Osho
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA
| | - Satish Chandrashekaran
- Department of Pulmonary and Critical Care, McKelvey Lung Transplant Center, Emory University Hospital, Atlanta, GA
| | | | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Division of Anesthesiology and Algology, University Hospitals Leuven, Leuven, Belgium
| | - Yoshiya Toyoda
- Division of Cardiovascular Surgery, Temple University, Philadelphia, PA
| | - Mohammed A Kashem
- Division of Cardiovascular Surgery, Temple University, Philadelphia, PA
| | - Stephen Huddleston
- Division of Cardiothoracic Surgery, University of Minnesota Medical School, Minneapolis, MI
| | - Naomi R Ryssel
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
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Wong W, Johnson B, Cheng PC, Josephson MB, Maeda K, Berg RA, Kawut SM, Harhay MO, Goldfarb SB, Yehya N, Himebauch AS. Primary graft dysfunction grade 3 following pediatric lung transplantation is associated with chronic lung allograft dysfunction. J Heart Lung Transplant 2023; 42:669-678. [PMID: 36639317 PMCID: PMC10811698 DOI: 10.1016/j.healun.2022.12.014] [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: 05/26/2022] [Revised: 12/01/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Severe primary graft dysfunction (PGD) is associated with the development of bronchiolitis obliterans syndrome (BOS), the most common form of chronic lung allograft dysfunction (CLAD), in adults. However, PGD associations with long-term outcomes following pediatric lung transplantation are unknown. We hypothesized that PGD grade 3 (PGD 3) at 48- or 72-hours would be associated with shorter CLAD-free survival following pediatric lung transplantation. METHODS This was a single center retrospective cohort study of patients ≤ 21 years of age who underwent bilateral lung transplantation between 2005 and 2019 with ≥ 1 year of follow-up. PGD and CLAD were defined by published criteria. We evaluated the association of PGD 3 at 48- or 72-hours with CLAD-free survival by using time-to-event analyses. RESULTS Fifty-one patients were included (median age 12.7 years; 51% female). The most common transplant indications were cystic fibrosis (29%) and pulmonary hypertension (20%). Seventeen patients (33%) had PGD 3 at either 48- or 72-hours. In unadjusted analysis, PGD 3 was associated with an increased risk of CLAD or mortality (HR 2.10, 95% CI 1.01-4.37, p=0.047). This association remained when adjusting individually for multiple potential confounders. There was evidence of effect modification by sex (interaction p = 0.055) with the association of PGD 3 and shorter CLAD-free survival driven predominantly by males (HR 4.73, 95% CI 1.44-15.6) rather than females (HR 1.23, 95% CI 0.47-3.20). CONCLUSIONS PGD 3 at 48- or 72-hours following pediatric lung transplantation was associated with shorter CLAD-free survival. Sex may be a modifier of this association.
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Affiliation(s)
- Wai Wong
- Department of Pediatrics, Division of Pulmonary Medicine and Respiratory Diseases, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Brandy Johnson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pi Chun Cheng
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Maureen B Josephson
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katsuhide Maeda
- Department of Surgery, Division of Cardiothoracic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samuel B Goldfarb
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, University of Minnesota, Masonic Children's Hospital, Minneapolis, Minnesota
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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5
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Avtaar Singh SS, Das De S, Al-Adhami A, Singh R, Hopkins PMA, Curry PA. Primary graft dysfunction following lung transplantation: From pathogenesis to future frontiers. World J Transplant 2023; 13:58-85. [PMID: 36968136 PMCID: PMC10037231 DOI: 10.5500/wjt.v13.i3.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/11/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023] Open
Abstract
Lung transplantation is the treatment of choice for patients with end-stage lung disease. Currently, just under 5000 lung transplants are performed worldwide annually. However, a major scourge leading to 90-d and 1-year mortality remains primary graft dysfunction. It is a spectrum of lung injury ranging from mild to severe depending on the level of hypoxaemia and lung injury post-transplant. This review aims to provide an in-depth analysis of the epidemiology, pathophysiology, risk factors, outcomes, and future frontiers involved in mitigating primary graft dysfunction. The current diagnostic criteria are examined alongside changes from the previous definition. We also highlight the issues surrounding chronic lung allograft dysfunction and identify the novel therapies available for ex-vivo lung perfusion. Although primary graft dysfunction remains a significant contributor to 90-d and 1-year mortality, ongoing research and development abreast with current technological advancements have shed some light on the issue in pursuit of future diagnostic and therapeutic tools.
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Affiliation(s)
- Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, United Kingdom
| | - Sudeep Das De
- Heart and Lung Transplant Unit, Wythenshawe Hospital, Manchester M23 9NJ, United Kingdom
| | - Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
- Department of Heart and Lung Transplant, Royal Papworth Hospital, Cambridge CB2 0AY, United Kingdom
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, VA 22042, United States
| | - Peter MA Hopkins
- Queensland Lung Transplant Service, Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Philip Alan Curry
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow G81 4DY, United Kingdom
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6
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Natalini JG, Clausen ES. Critical Care Management of the Lung Transplant Recipient. Clin Chest Med 2023; 44:105-119. [PMID: 36774158 DOI: 10.1016/j.ccm.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation is often the only treatment option for patients with severe irreversible lung disease. Improvements in donor and recipient selection, organ allocation, surgical techniques, and immunosuppression have all contributed to better survival outcomes after lung transplantation. Nonetheless, lung transplant recipients still experience frequent complications, often necessitating treatment in an intensive care setting. In addition, the use of extracorporeal life support as a means of bridging critically ill patients to lung transplantation has become more widespread. This review focuses on the critical care aspects of lung transplantation, both before and after surgery.
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Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, 530 First Avenue, HCC 4A, New York, NY 10016, USA.
| | - Emily S Clausen
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9036 Gates Building, Philadelphia, PA 19104, USA
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7
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Isaza E, Santos J, Haro GJ, Chen J, Weber DJ, Deuse T, Singer JP, Golden JA, Hays S, Trinh BN, Brzezinski M, Kukreja J. Intercostal Nerve Cryoanalgesia Versus Thoracic Epidural Analgesia in Lung Transplantation: A Retrospective Single-Center Study. Pain Ther 2023; 12:201-211. [PMID: 36274081 PMCID: PMC9845479 DOI: 10.1007/s40122-022-00448-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/07/2022] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION The optimal pain management strategy after lung transplantation is unknown. This study compared analgesic outcomes of intercostal nerve blockade by cryoanalgesia (Cryo) versus thoracic epidural analgesia (TEA). METHODS Seventy-two patients who underwent bilateral lung transplantation via clamshell incision at our center from 2016 to 2018 were managed with TEA (N = 43) or Cryo (N = 29). We evaluated analgesic-specific complications, opioid use in oral morphine equivalents (OME), and pain scores (0-10) through postoperative day 7. Adjusted linear regression was used to assess for non-inferiority of Cryo to TEA. RESULTS The overall mean pain scores (Cryo 3.2 vs TEA 3.8, P = 0.21), maximum mean pain scores (Cryo 4.7 vs TEA 5.5, P = 0.16), and the total opioid use (Cryo 484 vs TEA 705 OME, P = 0.12) were similar in both groups, while the utilization of postoperative opioid-sparing analgesia, measured as use of lidocaine patches, was lower in the Cryo group (Cryo 21% vs TEA 84%, P < 0.001). Analgesic outcomes remained similar between the cohorts after adjustment for pertinent patient and analgesic characteristics (P = 0.26), as well as after exclusion of Cryo patients requiring rescue TEA (P = 0.32). There were no Cryo complications, with four patients requiring subsequent TEA for pain control. Two TEA patients experienced hemodynamic instability following a test TEA bolus requiring code measures. Additionally, TEA placement was delayed beyond postoperative day 1 in 33% owing to need for anticoagulation or clinical instability. CONCLUSIONS In lung transplantation, Cryo was found to be safe with analgesic effectiveness similar to TEA. Cryo may be advantageous in this complex patient population, as it can be used in all clinical scenarios and eliminates risks and delays associated with TEA.
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Affiliation(s)
- Erin Isaza
- grid.266102.10000 0001 2297 6811School of Medicine, University of California, San Francisco, San Francisco, USA
| | - Jesse Santos
- grid.266102.10000 0001 2297 6811Department of Surgery, University of California, San Francisco, East Bay, San Francisco, USA
| | - Greg J. Haro
- grid.266102.10000 0001 2297 6811Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, 500 Parnassus Ave, Suite MUW-405, San Francisco, CA 94143-0118 USA
| | - Joy Chen
- grid.266102.10000 0001 2297 6811Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, 500 Parnassus Ave, Suite MUW-405, San Francisco, CA 94143-0118 USA
| | - Daniel J. Weber
- grid.266102.10000 0001 2297 6811Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, 500 Parnassus Ave, Suite MUW-405, San Francisco, CA 94143-0118 USA
| | - Tobias Deuse
- grid.266102.10000 0001 2297 6811Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, 500 Parnassus Ave, Suite MUW-405, San Francisco, CA 94143-0118 USA
| | - Jonathan P. Singer
- grid.266102.10000 0001 2297 6811Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Jeffrey A. Golden
- grid.266102.10000 0001 2297 6811Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Steven Hays
- grid.266102.10000 0001 2297 6811Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, USA
| | - Binh N. Trinh
- grid.266102.10000 0001 2297 6811Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, 500 Parnassus Ave, Suite MUW-405, San Francisco, CA 94143-0118 USA
| | - Marek Brzezinski
- grid.266102.10000 0001 2297 6811Department of Anesthesia, University of California, San Francisco, San Francisco, USA
| | - Jasleen Kukreja
- grid.266102.10000 0001 2297 6811Division of Cardiothoracic Surgery, Department of Surgery, University of California, San Francisco, 500 Parnassus Ave, Suite MUW-405, San Francisco, CA 94143-0118 USA
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Takahashi T, Terada Y, Pasque MK, Nava RG, Kozower BD, Meyers BF, Patterson GA, Kreisel D, Puri V, Hachem RR. Outcomes of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation. Ann Thorac Surg 2023; 115:1273-1280. [PMID: 36634836 DOI: 10.1016/j.athoracsur.2022.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Primary graft dysfunction (PGD) is the leading cause of death in the first 30 days after lung transplantation and is also associated with worse long-term outcomes. Outcomes of patients with PGD grade 3 requiring extracorporeal membrane oxygenation (ECMO) support after lung transplantation have yet to be well described. We sought to describe short- and long-term outcomes for patients with PGD grade 3 who required ECMO support. METHODS This is a single-center retrospective cohort study of patients undergoing lung transplantation. We stratified patients with PGD grade 3 into non-ECMO, venoarterial (VA) ECMO, and venovenous (VV) ECMO groups after transplantation. We then compared the outcomes between the groups. RESULTS Of 773 lung transplant recipients, PGD grade 3 developed in 204 (26%) at any time in the first 72 hours after lung transplantation. Of these, 13 (5%) required VA ECMO and 25 (10%) required VV ECMO support. The 30-day, 1-year, and 5-year survival in the VA ECMO group was 62%, 54%, and 43% compared with 96%, 84%, and 65% in the VV ECMO group and 99%, 94%, and 71% in the non-ECMO group. Multivariable Cox regression analysis showed that VA ECMO was associated with increased mortality (hazard ratio, 2.37; 95% CI, 1.06-5.28; P = .04). CONCLUSIONS Patients who required VA ECMO support for PGD grade 3 have significantly worse survival compared with those who did not require ECMO and those who required VV ECMO support. This suggests that VA ECMO treatment of patients with PGD grade 3 after lung transplantation can be a predictable risk factor for mortality.
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Affiliation(s)
- Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri.
| | - Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
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9
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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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10
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Perez AA, Shah RJ. Critical Care of the Lung Transplant Patient. Clin Chest Med 2022; 43:457-470. [PMID: 36116814 DOI: 10.1016/j.ccm.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Lung transplantation is a therapeutic option for end-stage lung disease that improves survival and quality of life. Prelung transplant admission to the intensive care unit (ICU) for bridge to transplant with mechanical ventilation and extracorporeal membrane oxygenation (ECMO) is common. Primary graft dysfunction is an important immediate complication of lung transplantation with short- and long-term morbidity and mortality. Later transplant-related causes of respiratory failure necessitating ICU admission include acute cellular rejection, atypical infections, and chronic lung allograft dysfunction. Lung transplantation for COVID-19-related ARDS is increasingly common..
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Affiliation(s)
- Alyssa A Perez
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, 400 Parnassus Street, 5th Floor, San Francisco, CA 94143, USA.
| | - Rupal J Shah
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, 400 Parnassus Street, 5th Floor, San Francisco, CA 94143, USA
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11
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Zhao Y, Su Y, Duan R, Song J, Liu X, Shen L, Ding J, Zhang P, Bao M, Chen C, Zhu Y, Jiang G, Li Y. Extracorporeal membrane oxygenation support for lung transplantation: Initial experience in a single center in China and a literature review. Front Med (Lausanne) 2022; 9:950233. [PMID: 35911420 PMCID: PMC9334721 DOI: 10.3389/fmed.2022.950233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) is a versatile tool associated with favorable outcomes in the field of lung transplantation (LTx). Here, the clinical outcomes and complications of patients who underwent LTx with ECMO support, mainly prophylactically both intraoperatively and post-operatively, in a single center in China are reviewed. Methods The study cohort included all consecutive patients who underwent LTx between January 2020 and January 2022. Demographics and LTx data were retrospectively reviewed. Perioperative results, including complications and survival outcomes, were assessed. Results Of 86 patients included in the study, 32 received ECMO support, including 21 who received prophylactic intraoperative use of ECMO with or without prolonged post-operative use (pro-ECMO group), while the remaining 54 (62.8%) received no external support (non-ECMO group). There were no significant differences in the incidence of grade 3 primary graft dysfunction (PGD), short-term survival, or perioperative outcomes and complications between the non-ECMO and pro-ECMO groups. However, the estimated 1- and 2-year survival were superior in the pro-ECMO group, although this difference was not statistically significant (64.1% vs. 82.4%, log-rank P = 0.152; 46.5% vs. 72.1%, log-rank P = 0.182, respectively). After regrouping based on the reason for ECMO support, 30-day survival was satisfactory, while 90-day survival was poor in patients who received ECMO as a bridge to transplantation. However, prophylactic intraoperative use of ECMO and post-operative ECMO prolongation demonstrated promising survival and acceptable complication rates. In particular, patients who initially received venovenous (VV) ECMO intraoperatively with the same configuration post-operatively achieved excellent outcomes. The use of ECMO to salvage a graft affected by severe PGD also achieved acceptable survival in the rescue group. Conclusions Prophylactic intraoperative ECMO support and post-operative ECMO prolongation demonstrated promising survival outcomes and acceptable complications in LTx patients. Particularly, VV ECMO provided safe and effective support intraoperatively and prophylactic prolongation reduced the incidence of PGD in selected patients. However, since this study was conducted in a relatively low-volume transplant center, further studies are needed to validate the results.
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Affiliation(s)
- Yanfeng Zhao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yiliang Su
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ruowang Duan
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jiong Song
- Department of Anesthesiology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiaogang Liu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lei Shen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Junrong Ding
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Pei Zhang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Minwei Bao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuming Zhu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuping Li
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
- *Correspondence: Yuping Li
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12
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Clausen E, Cantu E. Primary graft dysfunction: what we know. J Thorac Dis 2022; 13:6618-6627. [PMID: 34992840 PMCID: PMC8662499 DOI: 10.21037/jtd-2021-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/21/2021] [Indexed: 12/19/2022]
Abstract
Many advances in lung transplant have occurred over the last few decades in the understanding of primary graft dysfunction (PGD) though effective prevention and treatment remain elusive. This review will cover prior understanding of PGD, recent findings, and directions for future research. A consensus statement updating the definition of PGD in 2016 highlights the growing complexity of lung transplant perioperative care taking into account the increasing use of high flow oxygen delivery and pulmonary vasodilators in the current era. PGD, particularly more severe grades, is associated with worse short- and long-term outcomes after transplant such as chronic lung allograft dysfunction. Growing experience have helped identify recipient, donor, and intraoperative risk factors for PGD. Understanding the pathophysiology of PGD has advanced with increasing knowledge of the role of innate immune response, humoral cell immunity, and epithelial cell injury. Supportive care post-transplant with technological advances in extracorporeal membranous oxygenation (ECMO) remain the mainstay of treatment for severe PGD. Future directions include the evolving utility of ex vivo lung perfusion (EVLP) both in PGD research and potential pre-transplant treatment applications. PGD remains an important outcome in lung transplant and the future holds a lot of potential for improvement in understanding its pathophysiology as well as development of preventative therapies and treatment.
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Affiliation(s)
- Emily Clausen
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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13
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Abstract
The number of lung transplantations is progressively increasing worldwide, providing new challenges to interprofessional teams and the intensive care units. The outcome of lung transplantation recipients is critically affected by a complex interplay of particular pathophysiologic conditions and risk factors, knowledge of which is fundamental to appropriately manage these patients during the early postoperative course. As high-grade evidence-based guidelines are not available, the authors aimed to provide an updated review of the postoperative management of lung transplantation recipients in the intensive care unit, which addresses six main areas: (1) management of mechanical ventilation, (2) fluid and hemodynamic management, (3) immunosuppressive therapies, (4) prevention and management of neurologic complications, (5) antimicrobial therapy, and (6) management of nutritional support and abdominal complications. The integrated care provided by a dedicated multidisciplinary team is key to optimize the complex postoperative management of lung transplantation recipients in the intensive care unit.
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Li C, Pajoumand M, Lambert K, Najia L, Bathula AL, Mazzeffi MA, Galvagno SM, Tabatabai A, Grazioli A, Dahi S, Hochberg ES, Plazak ME. New-Onset Atrial Arrhythmias Are Independently Associated With In-Hospital Mortality in Veno-Venous Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 36:1648-1655. [DOI: 10.1053/j.jvca.2021.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 12/16/2022]
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B, Vicente Guillén R. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Copeland H, Levine D, Morton J, Hayanga JA. Acute respiratory distress syndrome in the cardiothoracic patient: State of the art and use of veno-venous extracorporeal membrane oxygenation. ACTA ACUST UNITED AC 2021; 8:97-103. [PMID: 34723221 PMCID: PMC8541831 DOI: 10.1016/j.xjon.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 10/12/2021] [Indexed: 01/02/2023]
Affiliation(s)
- Hannah Copeland
- Division of Cardiovascular Surgery, Division of Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital, Fort Wayne, Ind
- Indiana University School of Medicine Fort Wayne, Fort Wayne, Ind
- Address for reprints: Hannah Copeland, MD, Indiana University–Fort Wayne School of Medicine, 7910 W Jefferson Blvd, Suite 102, Fort Wayne, IN 46804.
| | - Deborah Levine
- Division of Pulmonary Critical Care and Lung Transplantation, Department of Medicine, University of Texas San Antonio, San Antonio, Tex
| | - John Morton
- Division of Cardiovascular Surgery, Division of Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital, Fort Wayne, Ind
| | - J.W. Awori Hayanga
- Department of Thoracic and Cardiovascular Surgery, West Virginia University, Morgantown, WVa
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez AI, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B, Vicente Guillén R. SEDAR/SECCE ECMO management consensus document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:443-471. [PMID: 34535426 DOI: 10.1016/j.redare.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/14/2020] [Indexed: 06/13/2023]
Abstract
ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.
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Affiliation(s)
- I Zarragoikoetxea
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - I Moreno
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J Porta
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - T Koller
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - V Cegarra
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A I Gonzalez
- Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain
| | - M Eiras
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain
| | - E Sandoval
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Aurelio Sarralde
- Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - B Quintana-Villamandos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Sekulovski M, Simonska B, Peruhova M, Krastev B, Peshevska-Sekulovska M, Spassov L, Velikova T. Factors affecting complications development and mortality after single lung transplant. World J Transplant 2021; 11:320-334. [PMID: 34447669 PMCID: PMC8371496 DOI: 10.5500/wjt.v11.i8.320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/15/2021] [Accepted: 06/28/2021] [Indexed: 02/06/2023] Open
Abstract
Lung transplantation (LT) is a life-saving therapeutic procedure that prolongs survival in patients with end-stage lung disease. Furthermore, as a therapeutic option for high-risk candidates, single LT (SLT) can be feasible because the immediate morbidity and mortality after transplantation are lower compared to sequential single (double) LT (SSLTx). Still, the long-term overall survival is, in general, better for SSLTx. Despite the great success over the years, the early post-SLT period remains a perilous time for these patients. Patients who undergo SLT are predisposed to evolving early or late postoperative complications. This review emphasizes factors leading to post-SLT complications in the early and late periods including primary graft dysfunction and chronic lung allograft dysfunction, native lung complications, anastomosis complications, infections, cardiovascular, gastrointestinal, renal, and metabolite complications, and their association with morbidity and mortality in these patients. Furthermore, we discuss the incidence of malignancy after SLT and their correlation with immunosuppression therapy.
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Affiliation(s)
- Metodija Sekulovski
- Department of Anesthesiology and Intensive care, University Hospital Lozenetz, Sofia 1407, Bulgaria
- Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria
| | - Bilyana Simonska
- Department of Anesthesiology and Intensive care, University Hospital Lozenetz, Sofia 1407, Bulgaria
| | - Milena Peruhova
- Department of Gastroenterology, University Hospital Lozenetz, Sofia 1407, Bulgaria
| | - Boris Krastev
- Department of Clinical Oncology, MHAT Hospital for Women Health Nadezhda, Sofia 1330, Bulgaria
| | | | - Lubomir Spassov
- Department of Cardiothoracic Surgery, University Hospital Lozenetz, Sofia 1431, Bulgaria
| | - Tsvetelina Velikova
- Department of Clinical Immunology, University Hospital Lozenetz, Sofia 1407, Bulgaria
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Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is a devastating complication in the acute postoperative lung transplant period, associated with high short-term mortality and chronic rejection. We review its definition, pathophysiology, risk factors, prevention, treatment strategies, and future research directions. RECENT FINDINGS New analyses suggest donation after circulatory death and donation after brain death donors have similar PGD rates, whereas donors >55 years are not associated with increased PGD risk. Recipient pretransplant diastolic dysfunction and overweight or obese recipients with predominant abdominal subcutaneous adipose tissue have increased PGD risk. Newly identified recipient biomarkers and donor and recipient genes increase PGD risk, but their clinical utility remains unclear. Mixed data still exists regarding cold ischemic time and PGD risk, and increased PGD risk with cardiopulmonary bypass remains confounded by transfusions. Portable ex vivo lung perfusion (EVLP) may prevent PGD, but its use is limited to a handful of centers. Although updates to current PGD treatment are lacking, future therapies are promising with targeted therapy and the use of EVLP to pharmacologically recondition donor lungs. SUMMARY There is significant progress in defining PGD and identifying its several risk factors, but effective prevention and treatment strategies are needed.
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Natalini JG, Diamond JM. Primary Graft Dysfunction. Semin Respir Crit Care Med 2021; 42:368-379. [PMID: 34030200 DOI: 10.1055/s-0041-1728794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Primary graft dysfunction (PGD) is a form of acute lung injury after transplantation characterized by hypoxemia and the development of alveolar infiltrates on chest radiograph that occurs within 72 hours of reperfusion. PGD is among the most common early complications following lung transplantation and significantly contributes to increased short-term morbidity and mortality. In addition, severe PGD has been associated with higher 90-day and 1-year mortality rates compared with absent or less severe PGD and is a significant risk factor for the subsequent development of chronic lung allograft dysfunction. The International Society for Heart and Lung Transplantation released updated consensus guidelines in 2017, defining grade 3 PGD, the most severe form, by the presence of alveolar infiltrates and a ratio of PaO2:FiO2 less than 200. Multiple donor-related, recipient-related, and perioperative risk factors for PGD have been identified, many of which are potentially modifiable. Consistently identified risk factors include donor tobacco and alcohol use; increased recipient body mass index; recipient history of pulmonary hypertension, sarcoidosis, or pulmonary fibrosis; single lung transplantation; and use of cardiopulmonary bypass, among others. Several cellular pathways have been implicated in the pathogenesis of PGD, thus presenting several possible therapeutic targets for preventing and treating PGD. Notably, use of ex vivo lung perfusion (EVLP) has become more widespread and offers a potential platform to safely investigate novel PGD treatments while expanding the lung donor pool. Even in the presence of significantly prolonged ischemic times, EVLP has not been associated with an increased risk for PGD.
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Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Sunder T. Extracorporeal membrane oxygenation and lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 37:327-337. [PMID: 33487892 PMCID: PMC7813619 DOI: 10.1007/s12055-020-01099-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/29/2022] Open
Abstract
The use of extracorporeal membrane oxygenation has had a positive impact on the outcomes after lung transplantation. Extracorporeal membrane oxygenation has a role in all phases of lung transplantation-preoperative, intraoperative, and postoperative periods. It serves as a bridge to transplantation in appropriate patients awaiting lung transplantation. Extracorporeal membrane oxygenation is used as a preferred method of cardiopulmonary support in some centres during implantation; and, after lung transplantation, it can be used to salvage the implanted lung in cases of severe primary graft dysfunction or as a planned extension of intraoperative extracorporeal membrane oxygenation onto the postoperative period. It has now gained acceptance as a mandatory tool in most lung transplant units. This article reviews the history of extracorporeal membrane oxygenation and lung transplantation, their subsequent development, and the current use of extracorporeal membrane oxygenation during lung transplantation. Our institutional practice and experience are described. The implications of the current global coronavirus disease pandemic on extracorporeal membrane oxygenation and lung transplantation are also briefly discussed.
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22
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Evaluation, Treatment, and Impact of Neurologic Injury in Adult Patients on Extracorporeal Membrane Oxygenation: a Review. Curr Treat Options Neurol 2021; 23:15. [PMID: 33814895 PMCID: PMC8009934 DOI: 10.1007/s11940-021-00671-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 01/21/2023]
Abstract
Purpose Extracorporeal membrane oxygen (ECMO) is increasingly used as an advanced form of life support for cardiac and respiratory failure. Unfortunately, in infrequent instances, circulatory and/or respiratory recovery is overshadowed by neurologic injury that can occur in patients who require ECMO. As such, knowledge of ECMO and its implications on diagnosis and treatment of neurologic injuries is indispensable for intensivists and neurospecialists. Recent findings The most common neurologic injuries include intracerebral hemorrhage, ischemic stroke, seizure, cerebral edema, intracranial hypertension, global cerebral hypoxia/anoxia, and brain death. These result from events prior to initiation of ECMO, failure of ECMO to provide adequate oxygen delivery, and/or complications that occur during ECMO. ECMO survivors also experience neurological and psychological sequelae similar to other survivors of critical illness. Summary Since many of the risk factors for neurologic injury cannot be easily mitigated, early diagnosis and intervention are crucial to limit morbidity and mortality from neurologic injury during ECMO.
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Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation. ASAIO J 2021; 67:1071-1078. [PMID: 33470638 DOI: 10.1097/mat.0000000000001350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is used as the last resort for primary graft dysfunction (PGD). The aim of this study is to explore the predictors and outcomes for early mortality in postlung transplant patients who required ECMO for PGD. Between January 2006 and December 2015, 1,049 cases of lung transplantation were performed at our center. Ninety-six patients required ECMO support after lung transplantation, 52 patients (54%) had PGD. Seven patients (13.5%) required venoarterial ECMO due to concomitant hemodynamical instability, and the others required venovenous ECMO. The patients were on ECMO for 5.00 ± 10.6 days. Forty-four patients (84.6%) were successfully decannulated. The 90 day, 1 year, and 5 year survival of patients who required ECMO for PGD after lung transplantation were 67.3%, 50.0%, and 31.5%, respectively. Cox regression indicated that when the patient was placed on ECMO later than 48 hours after transplantation, the patient could have higher in-house mortality (hazard ratio, 2.79; 95% CI, 1.21-6.43) and also higher 3 year mortality (hazard ratio, 2.30; 95% CI, 1.13-4.68) regardless of the patients' preoperative conditions or complexity of lung transplantation. Earlier recognition of PGD and initiation of ECMO may be beneficial in this population.
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Ischemia-reperfusion Injury in the Transplanted Lung: A Literature Review. Transplant Direct 2021; 7:e652. [PMID: 33437867 PMCID: PMC7793349 DOI: 10.1097/txd.0000000000001104] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/04/2020] [Accepted: 11/06/2020] [Indexed: 02/07/2023] Open
Abstract
Lung ischemia-reperfusion injury (LIRI) and primary graft dysfunction are leading causes of morbidity and mortality among lung transplant recipients. Although extensive research endeavors have been undertaken, few preventative and therapeutic treatments have emerged for clinical use. Novel strategies are still needed to improve outcomes after lung transplantation. In this review, we discuss the underlying mechanisms of transplanted LIRI, potential modifiable targets, current practices, and areas of ongoing investigation to reduce LIRI and primary graft dysfunction in lung transplant recipients.
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Fessler J, Sage E, Roux A, Feliot E, Gayat E, Pirracchio R, Parquin F, Cerf C, Fischler M, Le Guen M. Is Extracorporeal Membrane Oxygenation Withdrawal a Safe Option After Double-Lung Transplantation? Ann Thorac Surg 2020; 110:1167-1174. [DOI: 10.1016/j.athoracsur.2020.03.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 02/24/2020] [Accepted: 03/23/2020] [Indexed: 01/04/2023]
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26
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Vayvada M, Uygun Y, Cıtak S, Sarıbas E, Erkılıc A, Tasci E. Extracorporeal membrane oxygenation as a bridge to lung transplantation in a Turkish lung transplantation program: our initial experience. J Artif Organs 2020; 24:36-43. [PMID: 32852668 PMCID: PMC7450232 DOI: 10.1007/s10047-020-01204-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/12/2020] [Indexed: 11/07/2022]
Abstract
Lung transplantation is a life-saving treatment for patients with end-stage lung disease. Although the number of lung transplants has increased over the years, the number of available donor lungs has not increased at the same rate, leading to the death of transplant candidates on waiting lists. In this paper, we presented our initial experience with the use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. Between December 2016 and August 2018, we retrospectively reviewed the use of ECMO as a bridge to lung transplantation. Thirteen patients underwent preparative ECMO for bridging to lung transplantation, and seven patients successfully underwent bridging to lung transplantation. The average age of the patients was 45.7 years (range, 19–62 years). The ECMO support period lasted 3–55 days (mean, 18.7 days; median, 13 days). In seven patients, bridging to lung transplantation was performed successfully. The mean age of patients was 49.8 years (range 42–62). Bridging time was 3–55 days (mean, 19 days; median, 13 days). Two patients died in the early postoperative period. Five patients survived until discharge from the hospital. One-year survival was achieved in four patients. ECMO can be used safely for a long time to meet the physiological needs of critically ill patients. The use of ECMO as a bridge to lung transplantation is an acceptable treatment option to reduce the number of deaths on the waiting list. Despite the successful results achieved, this approach still involves risks and complications.
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Affiliation(s)
- Mustafa Vayvada
- Thoracic Surgery, Kartal Kosuyolu Training and Research Hospital, K Blok Cevizli, Kartal, Istanbul, Turkey.
| | - Yesim Uygun
- Infectious Diseases, Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
| | - Sevinc Cıtak
- Thoracic Surgery, Kartal Kosuyolu Training and Research Hospital, K Blok Cevizli, Kartal, Istanbul, Turkey
| | - Ertan Sarıbas
- Chest Diseases, Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
| | - Atakan Erkılıc
- Anesthesia and Reanimation, Kartal Kosuyolu Training and Research Hospital, Istanbul, Turkey
| | - Erdal Tasci
- Thoracic Surgery, Kartal Kosuyolu Training and Research Hospital, K Blok Cevizli, Kartal, Istanbul, Turkey
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27
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Martin AK, Jayaraman AL, Nabzdyk CG, Wilkey BJ, Fritz AV, Kolarczyk L, Ramakrishna H. Extracorporeal Membrane Oxygenation in Lung Transplantation: Analysis of Techniques and Outcomes. J Cardiothorac Vasc Anesth 2020; 35:644-661. [PMID: 32546408 DOI: 10.1053/j.jvca.2020.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/10/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Arun L Jayaraman
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, AZ
| | - Christoph G Nabzdyk
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Barbara J Wilkey
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Hayanga JWA, Hayanga HK, Fugett JH, Musgrove KA, Abbas G, Ensor CR, Badhwar V, Shigemura N. Contemporary look at extracorporeal membrane oxygenation as a bridge to reoperative lung transplantation in the United States - a retrospective study. Transpl Int 2020; 33:895-901. [PMID: 32299135 DOI: 10.1111/tri.13617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/11/2019] [Accepted: 04/10/2020] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to examine the influence of extracorporeal membrane oxygenation (ECMO) as a bridge to reoperative lung transplantation (LT) on outcomes and survival. A total of 1960 LT recipients transplanted a second time between 2005 and 2017 were analyzed using the United Network for Organ Sharing (UNOS) Organ Procurement and Transplantation Network (OPTN). Of these recipients, 99 needed ECMO as a bridge to reoperative LT. Mean age was 50 ± 14 years, 47% were females, and the group with ECMO was younger [42 (30-59) vs. 55 (40-62) years]. In both univariate and multivariable analyses (adjusting for age and gender), the ECMO group had greater incidence of prolonged ventilation >48 h (83% vs. 40%, P < 0.001) and in-hospital dialysis (27% vs. 7%, P < 0.001). There were no differences in incidence of acute rejection (15% vs. 11%, P = 0.205), airway dehiscence (4% vs. 2%, P = 0.083), stroke (3% vs. 2%, P = 0.731), or reintubation (20% vs. 20%, P = 0.998). Kaplan-Meier survival analysis showed the ECMO group had reduced 1-year survival (66.6% vs. 83.0%, P < 0.001). After covariate adjustment, the ECMO group only had increased risk for 1-year mortality in the 2005-2011 era (HR = 2.57, 95% CI = 1.45-4.57, P = 0.001). For patients who require reoperative LT, bridging with ECMO was historically a significant predictor of poor outcome, but may be improving in recent years.
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Affiliation(s)
| | - Heather K Hayanga
- Division of Cardiovascular Anesthesia, WVU Heart & Vascular Institute, West Virginia University, Morgantown, WV, USA
| | - James H Fugett
- Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University, Morgantown, WV, USA
| | - Kelsey A Musgrove
- Department of General Surgery, West Virginia University, Morgantown, WV, USA
| | - Ghulam Abbas
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | | | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, Temple University Health System, Philadelphia, PA, USA
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29
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Hayanga JWA, Chan EG, Musgrove K, Leung A, Shigemura N, Hayanga HK. Extracorporeal Membrane Oxygenation in the Perioperative Care of the Lung Transplant Patient. Semin Cardiothorac Vasc Anesth 2020; 24:45-53. [PMID: 31893982 DOI: 10.1177/1089253219896123] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lung transplantation (LT) is definitive therapy for end-stage lung disease. Donor allocation based on medical urgency has led to an increased trend in the transplantation of sicker and older patients. Mechanical ventilation (MV) formerly was the only method of bridging high-acuity patients to LT. When the physiological demands of ventilatory support exceeds the capability of MV, extracorporeal membrane oxygenation (ECMO) may become necessary. Recent improvements in ECMO technology and component design have led to a resurgence of interest in its use before, during, and after LT. Survival with ECMO as a bridge to LT has improved over time, now with many centers reporting little or no difference in outcomes, and some even reporting better outcomes, as compared with MV. Extracorporeal life support may also be used intraoperatively. In many studies to date, ECMO or cardiopulmonary bypass (CPB) has been reserved for patients who became hemodynamically unstable during the procedure or patients who could not tolerate single-lung ventilation. Both methods of support are fraught with potential complications. However, multiple studies comparing ECMO with CPB have shown that intraoperative use of ECMO resulted in improved outcomes and overall survival as well as lower rates of bleeding complications. In order to further reduce complications associated with ECMO, planned intraoperative ECMO use is occasionally reserved for high-risk patients who might otherwise require CPB. Future studies will need to improve patient selection to fully take advantage of the use of ECMO in LT while minimizing its costs.
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Affiliation(s)
| | - Ernest G Chan
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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30
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Tipograf Y, Gannon WD, Foley NM, Hozain A, Ukita R, Warhoover M, McMaster W, Nesbitt JC, Shah AS, Bacchetta M. A Dual-Lumen Bicaval Cannula for Venovenous Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2019; 109:1047-1053. [PMID: 31863760 DOI: 10.1016/j.athoracsur.2019.10.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 09/12/2019] [Accepted: 10/21/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Single-site, dual-lumen venovenous extracorporeal membrane oxygenation ECMO) facilitates mobilization, reduces recirculation, and mitigates insertion and infectious risks of an additional access site. This study reports the experience with a bicaval dual-lumen cannula that comprises a robust physical design allowing for easy and safe cannulation, precise positioning and monitoring, and appropriate physiologic support for patients with acute respiratory failure. METHODS Statistical analysis was performed from data gathered retrospectively from the electronic medical records of 20 adult patients who were cannulated for ECMO with this bicaval dual-lumen cannula from August 2018 through May 2019. RESULTS Gas exchange and blood flow were optimized in all patients after cannulation (median pH, 7.42 [interquartile range {IQR}, 7.39, 7.44], ratio of arterial partial pressure of oxygen to fraction of inspired oxygen, 186.5 [Pao2:Fio2, 116.5, 247.0]; pump flow, 3.9 L/min [IQR, 3.1, 4.3]). Eleven patients (55%) were able to be freed from mechanical ventilation after cannulation, 9 (45%) patients underwent a tracheostomy procedure while undergoing ECMO, and no patients required reintubation. No morbidity or mortality was related to the cannulation strategy or the catheter. Two patients required cannula repositioning. Survival to decannulation was 90%, and survival to hospital discharge was 80%. CONCLUSIONS The bicaval dual-lumen cannula maintains the advantages of upper body single-site configuration to provide the adjunctive respiratory support necessary to facilitate awakening and rehabilitation while minimizing the use of invasive mechanical ventilation. This cannula introduces design qualities that may offer advantages for acute respiratory failure requiring venovenous ECMO.
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Affiliation(s)
- Yuliya Tipograf
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Surgery, Columbia University Medical Center, New York, New York
| | - Whitney D Gannon
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neal M Foley
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ahmed Hozain
- Department of Biomedical Engineering, Columbia University Medical Center, New York, New York
| | - Rei Ukita
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Warhoover
- Department of Perfusion, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William McMaster
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan C Nesbitt
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Engineering, Columbia University Medical Center, New York, New York.
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31
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Abstract
Lung transplantation is an accepted therapeutic option for end-stage lung diseases. Its history starts in the 1940s, initially hampered by early deaths due to perioperative problems and acute rejection. Improvement of surgical techniques and the introduction of immunosuppressive drugs resulted in longer survival. Chronic lung allograft dysfunction (CLAD), a new complication appeared and remains the most serious complication today. CLAD, the main reason why survival after lung transplantation is impaired compared to other solid-organ transplantations is characterized by a gradually increasing shortness of breath, reflected in a deterioration of pulmonary function status, respiratory insufficiency and possibly death.
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32
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Budd AN, Kozarek K, Kurihara C, Bharat A, Reynolds A, Kretzer A. Use of ProtekDuo as Veno-arterial and Veno-venous Extracorporeal Membrane Oxygenation During Bilateral Lung Transplantation. J Cardiothorac Vasc Anesth 2019; 33:2250-2254. [DOI: 10.1053/j.jvca.2018.12.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Indexed: 01/03/2023]
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33
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Yang C, Peng G, Xu X, Wei B, Yang H, He J. The technique of intraoperative axillary artery cannulation for extracorporeal membrane oxygenation in lung transplantation. J Thorac Dis 2019; 11:2939-2944. [PMID: 31463123 DOI: 10.21037/jtd.2019.07.32] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background To show our experiences of using the axillary artery with a side graft as a cannulation technique for the inflow of veno-arterial extracorporeal membrane oxygenation (ECMO) in lung transplantation (LTx). This method can avoid complications associated with central and femoral vessel cannulation techniques, and be convenient for the use of intraoperative ECMO into the early postoperative period. Methods Between November 2016 and July 2017, we established intraoperative V/A-ECMO in 32 patients. Among these patients, 5 patients were performed on via axillary artery-percutaneous femoral vein cannulation (15.6%), 2 patients were performed on with veno-venous ECMO (V/V-ECMO) as a bridge to transplantation with hemodynamic instability during transplantation, and additional axillary artery cannulations were performed to establish veno-veno-arterial (V/V/A) ECMO. Mean age was 45.2±10.1 years (range, 26-71 years). Results In 7 patients undergoing ECMO support during operation, the ECMO was removed in 4 patients immediately after the procedure, 3 patients with "prolonged ECMO" were transferred to the ICU. There were no ECMO-related complications and no patients died. Conclusions Our protocol for V/A-ECMO cannulation that uses the axillary artery for arterial cannulation provides a safe and improved means for delivering V/A-ECMO support during LTx. Also, it is helpful for prolonging the intraoperative ECMO in the early postoperative period.
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Affiliation(s)
- Chao Yang
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Guilin Peng
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Xin Xu
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Bing Wei
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Hanyu Yang
- Department of Anaesthesiology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
| | - Jianxing He
- Department of Thoracic and Transplant Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510120, China
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34
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Bellier J, Lhommet P, Bonnette P, Puyo P, Le Guen M, Roux A, Parquin F, Chapelier A, Sage E. Extracorporeal membrane oxygenation for grade 3 primary graft dysfunction after lung transplantation: Long‐term outcomes. Clin Transplant 2019; 33:e13480. [DOI: 10.1111/ctr.13480] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 01/05/2019] [Accepted: 01/07/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - Pierre Lhommet
- Thoracic Surgery Department Foch Hospital Suresnes France
| | | | - Philippe Puyo
- Thoracic Surgery Department Foch Hospital Suresnes France
| | | | - Antoine Roux
- Pneumology, Adult Cystic Fibrosis Center and Lung Transplantation Department Foch Hospital Suresnes France
| | | | | | - Edouard Sage
- Thoracic Surgery Department Foch Hospital Suresnes France
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35
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Abdelnour-Berchtold E, Federici S, Wurlod DA, Bellier J, Zellweger M, Kirsch M, Nicod L, Marcucci C, Baeriswyl M, Liaudet L, Soccal PM, Gonzalez M, Perentes JY, Ris HB, Krueger T, Aubert JD. Outcome after extracorporeal membrane oxygenation-bridged lung retransplants: a single-centre experience. Interact Cardiovasc Thorac Surg 2019; 28:922-928. [DOI: 10.1093/icvts/ivz013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 12/05/2018] [Accepted: 12/11/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Sara Federici
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Daniel-Adrien Wurlod
- Division of Pneumology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jocelyn Bellier
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Matthieu Zellweger
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Matthias Kirsch
- Division of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Laurent Nicod
- Division of Pneumology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Carlo Marcucci
- Division of Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Moira Baeriswyl
- Division of Anesthesiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Lucas Liaudet
- Division of Intensive Care, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Paola M Soccal
- Division of Pneumology, Hôpitaux Universitaires Genève, Geneva, Switzerland
| | - Michel Gonzalez
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jean Yannis Perentes
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Hans-Beat Ris
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thorsten Krueger
- Division of Thoracic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - John-David Aubert
- Division of Pneumology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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36
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Reeb J, Olland A, Massard G, Falcoz PE. Extracorporeal life support in thoracic surgery. Eur J Cardiothorac Surg 2019; 53:489-494. [PMID: 29340579 DOI: 10.1093/ejcts/ezx477] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jeremie Reeb
- The Strasbourg Lung Transplant Program, Department of Thoracic Surgery, Strasbourg University Hospital, Strasbourg, France.,Research unit EA 7293 'Vascular and Tissular Stress in Transplantation', Translational Research Federation, University of Strasbourg, Strasbourg, France
| | - Anne Olland
- The Strasbourg Lung Transplant Program, Department of Thoracic Surgery, Strasbourg University Hospital, Strasbourg, France.,Research unit EA 7293 'Vascular and Tissular Stress in Transplantation', Translational Research Federation, University of Strasbourg, Strasbourg, France
| | - Gilbert Massard
- The Strasbourg Lung Transplant Program, Department of Thoracic Surgery, Strasbourg University Hospital, Strasbourg, France.,Research unit EA 7293 'Vascular and Tissular Stress in Transplantation', Translational Research Federation, University of Strasbourg, Strasbourg, France
| | - Pierre-Emmanuel Falcoz
- The Strasbourg Lung Transplant Program, Department of Thoracic Surgery, Strasbourg University Hospital, Strasbourg, France
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37
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Rosenheck J, Pietras C, Cantu E. Early Graft Dysfunction after Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2018; 7:176-187. [PMID: 31548919 PMCID: PMC6756771 DOI: 10.1007/s13665-018-0213-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Primary graft dysfunction is an acute lung injury syndrome occurring immediately following lung transplantation. This review aims to provide an overview of the current understanding of PGD, including epidemiology, immunology, clinical outcomes and management. RECENT FINDINGS Identification of donor and recipient factors allowing accurate prediction of PGD has been actively pursued. Improved understanding of the immunology underlying PGD has spurred interest in identifying relevant biomarkers. Work in PGD prediction, severity stratification and targeted therapies continue to make progress. Donor expansion strategies continue to be pursued with ex vivo lung perfusion playing a prominent role. While care of PGD remains supportive, ECMO has established a prominent role in the early aggressive management of severe PGD. SUMMARY A consensus definition of PGD has allowed marked advances in research and clinical care of affected patients. Future research will lead to reliable predictive tools, and targeted therapeutics of this important syndrome.
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Affiliation(s)
- Justin Rosenheck
- Pulmonary, Allergy, and Critical Care Division, University
of Pennsylvania Perelman School of Medicine
| | - Colleen Pietras
- Department of Surgery, University of Pennsylvania Perelman
School of Medicine
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania Perelman
School of Medicine
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38
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Ius F, Tudorache I, Warnecke G. Extracorporeal support, during and after lung transplantation: the history of an idea. J Thorac Dis 2018; 10:5131-5148. [PMID: 30233890 DOI: 10.21037/jtd.2018.07.43] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
During recent years, continuous technological innovation has provoked an increase of extracorporeal life support (ECLS) use for perioperative cardiopulmonary support in lung transplantation. Initial results were disappointing, due to ECLS-specific complications and high surgical risk of the supported patients. However, the combination of improved patient management, multidisciplinary team work and standardization of ECLS protocols has recently yielded excellent results in several case series from high-volume transplant centres. Therein, it was demonstrated that, although the prevalence of complications remains higher in supported patients, there may be no difference in long-term graft function between supported and non-supported patients. These results are important, because most of the patients who require ECLS support in lung transplantation are young and have no other chance to survive, but to be transplanted. Moreover, there is no device for "bridging to destination" therapy in lung transplantation. Of note, the evidence in favour of ECLS support in lung transplantation was never validated by randomized controlled trials, but by everyday experience at the patient bed-side. Here, we review the state-of-the-art ECLS evidence for intraoperative and postoperative cardiopulmonary support in lung transplantation.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
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39
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Panchabhai TS, Chaddha U, McCurry KR, Bremner RM, Mehta AC. Historical perspectives of lung transplantation: connecting the dots. J Thorac Dis 2018; 10:4516-4531. [PMID: 30174905 DOI: 10.21037/jtd.2018.07.06] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lung transplantation is now a treatment option for many patients with end-stage lung disease. Now 55 years since the first human lung transplant, this is a good time to reflect upon the history of lung transplantation, to recognize major milestones in the field, and to learn from others' unsuccessful transplant experiences. James Hardy was instrumental in developing experimental thoracic transplantation, performing the first human lung transplant in 1963. George Magovern and Adolph Yates carried out the second human lung transplant a few days later. With a combined survival of only 26 days for these first 2 lung transplant recipients, the specialty of lung transplantation clearly had a long way to go. The first "successful" lung transplant, in which the recipient survived for 10.5 months, was reported by Fritz Derom in 1971. Ten years later, Bruce Reitz and colleagues performed the first successful en bloc transplantation of the heart and one lung with a single distal tracheal anastomosis. In 1988, Alexander Patterson performed the first successful double lung transplant. The modern technique of sequential double lung transplantation and anastomosis performed at the mainstem bronchus level was originally described by Henri Metras in 1950, but was not reintroduced into the field until Pasque reported it again in 1990. Since then, lung transplantation has seen landmark changes: evolving immunosuppression regimens, clarifying the definition of primary graft dysfunction (PGD), establishing the lung allocation score (LAS), introducing extracorporeal membrane oxygenation (ECMO) as a bridge to transplant, allowing donation after cardiac death, and implementing ex vivo perfusion, to name a few. This article attempts to connect the historical dots in this field of research, with the hope that our effort helps summarize what has been achieved, and identifies opportunities for future generations of transplant pulmonologists and surgeons alike.
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Affiliation(s)
- Tanmay S Panchabhai
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Udit Chaddha
- Department of Pulmonary and Critical Care Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Sydell and Arnold Miller Family Heart and Vascular Institute
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Atul C Mehta
- Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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40
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Pettenuzzo T, Faggi G, Di Gregorio G, Schiavon M, Marulli G, Gregori D, Rea F, Ori C, Feltracco P. Blood Products Transfusion and Mid-Term Outcomes of Lung Transplanted Patients Under Extracorporeal Membrane Oxygenation Support. Prog Transplant 2018; 28:314-321. [PMID: 29879861 DOI: 10.1177/1526924818765816] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is considered a reliable technique in lung transplantation requiring cardiorespiratory support. However, the impact of this technology on blood product transfusion rate and outcomes compared to off-pump lung transplantation has been rarely investigated. METHODS Between January 2012 and June 2015, 52 elective adult lung transplants were performed at our institution. Of these, 15 recipients required intraoperative venoarterial extracorporeal support and 37 did not. We compared blood product consumption and other outcome variables between the 2 groups. RESULTS We found comparable in-hospital (86.7% vs 97.3%, P = .14) and 6-month (86.7% vs 91.9%, P = .56) survival between patients with and without extracorporeal support, respectively. Survival at 30 days was lower in the ECMO group (86.7% vs 100%, P = .02). Although patients who underwent ECMO received more intraoperative transfusions, postoperative transfusion rate was similar between the 2 groups. The ECMO group experienced longer mechanical ventilation (median 3 vs 2 days, P = .02) and intensive care unit stay (median 7 vs 5 days, P = .02), besides more cardiogenic shock and deep vein thrombosis. However, we observed no difference in other major and minor in-hospital complications and 6-month complications. CONCLUSIONS In our experience, despite the higher need for intraoperative transfusions, lung transplantation performed with ECMO support is comparable to the off-pump procedure as to short-term survival and outcomes.
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Affiliation(s)
- Tommaso Pettenuzzo
- 1 Institute of Anesthesiology and Intensive Care, Department of Medicine, University of Padua, Padua, Italy
| | - Giulio Faggi
- 1 Institute of Anesthesiology and Intensive Care, Department of Medicine, University of Padua, Padua, Italy
| | - Guido Di Gregorio
- 1 Institute of Anesthesiology and Intensive Care, Department of Medicine, University of Padua, Padua, Italy
| | - Marco Schiavon
- 2 Division of Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Giuseppe Marulli
- 2 Division of Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Dario Gregori
- 3 Division of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Federico Rea
- 2 Division of Thoracic Surgery, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Carlo Ori
- 1 Institute of Anesthesiology and Intensive Care, Department of Medicine, University of Padua, Padua, Italy
| | - Paolo Feltracco
- 1 Institute of Anesthesiology and Intensive Care, Department of Medicine, University of Padua, Padua, Italy
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41
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Biswas Roy S, Panchanathan R, Walia R, Varsch KE, Kang P, Huang J, Hashimi AS, Mohanakumar T, Bremner RM, Smith MA. Lung Retransplantation for Chronic Rejection: A Single-Center Experience. Ann Thorac Surg 2018; 105:221-227. [DOI: 10.1016/j.athoracsur.2017.07.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 06/18/2017] [Accepted: 07/11/2017] [Indexed: 10/18/2022]
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42
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Riera J, Maldonado C, Mazo C, Martínez M, Baldirà J, Lagunes L, Augustin S, Roman A, Due M, Rello J, Levine DJ. Prone positioning as a bridge to recovery from refractory hypoxaemia following lung transplantation. Interact Cardiovasc Thorac Surg 2017; 25:292-296. [PMID: 28449046 DOI: 10.1093/icvts/ivx073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 02/08/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Refractory hypoxaemia is the leading cause of mortality in the postoperative period after lung transplantation. The role of prone positioning as a rescue therapy in this setting has not been assessed. We evaluated its effects in lung transplant recipients presenting refractory hypoxaemia following the surgery. METHODS Prospectively collected data from 131 consecutive adult patients undergoing lung transplantation between January 2013 and December 2014 were evaluated. Twenty-two patients received prone position therapy. Indications, associated complications, time to initiation and duration of the manoeuvre were analysed and the effects of prone position on gas exchange were evaluated. Finally, outcomes in this cohort were compared against the rest of lung transplant recipients. RESULTS Prone positioning was more frequently implemented within the first 72 h (68.2%) and its main indication was primary graft dysfunction. The manoeuvre was maintained during a median of 21 h. After prone position, the pressure of arterial oxygen/fraction of inspired oxygen ratio significantly increased from 81.0 mmHg [interquartile range (IQR) 71.5-104.0] to 220.0 (IQR 160.0-288.0) (P < 0.001). No complications related with the technique were reported. Patients who underwent the manoeuvre had longer hospital stay [50.0 days (IQR 36.0-67.0) vs 30.0 (IQR 23.0-56.0), P = 0.006] than the rest of the population. No differences were found comparing either 1-year mortality (9.1% vs 15.6%; P = 0.740) or 1-year graft function [forced expiratory volume in 1 second of 70.0 (IQR 53.0-83.0) vs 68.0 (IQR 53.5-80.5), P = 0.469]. CONCLUSIONS Prone positioning is safe and significantly improves gas exchange in patients with refractory hypoxaemia after lung transplantation. It should be considered as a possible treatment in these patients.
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Affiliation(s)
- Jordi Riera
- Department of Critical Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institute, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Carolina Maldonado
- Department of Critical Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristopher Mazo
- Department of Critical Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institute, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - María Martínez
- Department of Critical Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Baldirà
- Department of Critical Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Leonel Lagunes
- Department of Critical Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Salvador Augustin
- Department of Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institute, Barcelona, Spain.,Liver Unit, Department of Internal Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBERehd, Instituto de Salud Carlos III, Madrid, Spain
| | - Antonio Roman
- Department of Pneumology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Maria Due
- Department of Thoracic Surgery, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Rello
- Department of Critical Care, Vall d'Hebron University Hospital, Barcelona, Spain.,Department of Medicine, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institute, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Deborah J Levine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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Hoetzenecker K, Schwarz S, Muckenhuber M, Benazzo A, Frommlet F, Schweiger T, Bata O, Jaksch P, Ahmadi N, Muraközy G, Prosch H, Hager H, Roth G, Lang G, Taghavi S, Klepetko W. Intraoperative extracorporeal membrane oxygenation and the possibility of postoperative prolongation improve survival in bilateral lung transplantation. J Thorac Cardiovasc Surg 2017; 155:2193-2206.e3. [PMID: 29653665 DOI: 10.1016/j.jtcvs.2017.10.144] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 10/15/2017] [Accepted: 10/27/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The value of intraoperative extracorporeal membrane oxygenation (ECMO) in lung transplantation remains controversial. In our department, ECMO has been used routinely for intraoperatively unstable patients for more than 15 years. Recently, we have extended its indication to a preemptive application in almost all cases. In addition, we prolong ECMO into the early postoperative period whenever graft function does not meet certain quality criteria or in patients with primary pulmonary hypertension. The objective of this study was to review the results of this strategy. METHODS All standard bilateral lung transplantations performed between January 2010 and June 2016 were included in this single-center, retrospective analysis. Patients were divided into 3 groups: group I-no ECMO (n = 116), group II-intraoperative ECMO (n = 343), and group III-intraoperative and prolonged postoperative ECMO (n = 123). The impact of different ECMO strategies on primary graft function, short-term outcomes, and patient survival were analyzed. RESULTS The use of intraoperative ECMO was associated with improved 1-, 3-, and 5-year survival compared with non-ECMO patients (91% vs 82%, 85% vs 76%, and 80% vs 74%; log-rank P = .041). This effect was still evident after propensity score matching of both cohorts. Despite the high number of complex patients in group III, outcome was excellent with higher survival rates than in the non-ECMO group at all time points. CONCLUSIONS Intraoperative ECMO results in superior survival when compared with transplantation without any extracorporeal support. The concept of prophylactic postoperative ECMO prolongation is associated with excellent outcomes in recipients with pulmonary hypertension and in patients with questionable graft function at the end of implantation.
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Affiliation(s)
- Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Moritz Muckenhuber
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Alberto Benazzo
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Frommlet
- Department of Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Thomas Schweiger
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Orsolya Bata
- Department of Radiology, National Institute of Oncology, Budapest, Hungary
| | - Peter Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Negar Ahmadi
- Department of General Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Gabriella Muraközy
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Helmut Prosch
- Department of Radiology and Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Helmut Hager
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Georg Roth
- Department of Anaesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - György Lang
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria; Department of Thoracic Surgery, Semmelweis University, Budapest, Hungary
| | - Shahrokh Taghavi
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
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Song JH, Park JE, Lee JG, Lee CY, Nam KS, Suh JW, Kim A, Lee SH, Joo HC, Youn YN, Kim SY, Park MS, Paik HC. Outcomes of perioperative extracorporeal membrane oxygenation use in patients undergoing lung transplantation. J Thorac Dis 2017; 9:5075-5084. [PMID: 29312713 DOI: 10.21037/jtd.2017.10.142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background The aim of this single-center study is to review the transplant outcomes of patients receiving lung transplantation (LTx) using intraoperative extracorporeal membrane oxygenation (ECMO) according to the perioperative use of ECMO. Methods We retrospectively reviewed the transplant outcomes of 107 consecutive patients who underwent LTx using intraoperative ECMO between March 2013 and August 2016 at Severance Hospital of Yonsei University (Seoul, Korea). Results Patients were divided into the following three groups according to the use of perioperative ECMO: only intraoperative ECMO (n=47) or extended post-operative ECMO but no bridging and no postoperative ECMO re-implantation (secondary ECMO; n=28) as Group A (n=75); bridging ECMO without secondary ECMO (n=14) as Group B; and secondary ECMO with (n=7) or without (n=11) bridging as Group C. Baseline demographics were comparable among the three groups. The mean duration of preoperative ECMO bridging was 16.4±15.6 (n=21). After a median of 17.7 months (range, 3.1-40.9 months) for survivors, the one year overall survival (OS) rates after LTx for the three groups were 76.3%±5.2% for Group A, 59.9%±14.3% for Group B, and 14.0%±9.0% for Group C (P<0.0001). The secondary ECMO (Group C) was established a mean of 7.9±5.3 days after LTx. The main cause of secondary ECMO was acute respiratory failure from pneumonia, and the main cause of death was infection-related events. Conclusions Our data suggests that the use of perioperative ECMO, including its extended postoperative use during LTx, is feasible and has favorable outcomes. However, as shown by the poor survival outcome after secondary ECMO, the development of solid strategy to reduce the need for secondary ECMO implantation after LTx seems important.
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Affiliation(s)
- Joo Han Song
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Eun Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Young Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Nam
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Won Suh
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Anes Kim
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Chel Joo
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Nam Youn
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Song Yee Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Moo Suk Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Primary graft dysfunction is a form of acute injury after lung transplantation that is associated with significant short- and long-term morbidity and mortality. Multiple mechanisms contribute to the pathogenesis of primary graft dysfunction, including ischemia reperfusion injury, epithelial cell death, endothelial cell dysfunction, innate immune activation, oxidative stress, and release of inflammatory cytokines and chemokines. This article reviews the epidemiology, pathogenesis, risk factors, prevention, and treatment of primary graft dysfunction.
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Affiliation(s)
- Mary K Porteous
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA.
| | - James C Lee
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Reeb J, Olland A, Renaud S, Kindo M, Santelmo N, Massard G, Falcoz PE. Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica. EMC - TECNICHE CHIRURGICHE - CHIRURGIA GENERALE 2017. [PMCID: PMC7164803 DOI: 10.1016/s1636-5577(17)82113-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- J. Reeb
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
- The Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, 200, Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - A. Olland
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - S. Renaud
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - M. Kindo
- Service de chirurgie cardiovasculaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - N. Santelmo
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - G. Massard
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
| | - P.-E. Falcoz
- Service de chirurgie thoracique, Groupe de transplantation pulmonaire, Nouvel Hôpital civil, Hôpitaux universitaires de Strasbourg, 1, place de l’Hôpital, 67100 Strasbourg, France
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Diamond JM, Arcasoy S, Kennedy CC, Eberlein M, Singer JP, Patterson GM, Edelman JD, Dhillon G, Pena T, Kawut SM, Lee JC, Girgis R, Dark J, Thabut G. Report of the International Society for Heart and Lung Transplantation Working Group on Primary Lung Graft Dysfunction, part II: Epidemiology, risk factors, and outcomes—A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1104-1113. [DOI: 10.1016/j.healun.2017.07.020] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 11/28/2022] Open
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Report of the ISHLT Working Group on primary lung graft dysfunction Part IV: Prevention and treatment: A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1121-1136. [DOI: 10.1016/j.healun.2017.07.013] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 07/16/2017] [Indexed: 12/14/2022] Open
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49
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Acute postoperative management after lung transplantation. Best Pract Res Clin Anaesthesiol 2017; 31:273-284. [DOI: 10.1016/j.bpa.2017.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/03/2017] [Accepted: 07/12/2017] [Indexed: 01/02/2023]
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50
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[Extracorporeal life support in thoracic surgery: What are the indications and the pertinence?]. Rev Mal Respir 2017; 34:802-819. [PMID: 28502521 DOI: 10.1016/j.rmr.2016.10.879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 10/31/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION In thoracic surgery, extracorporeal life support (ECLS) technologies are used in cases of severe and refractory respiratory failure or as intraoperative cardiorespiratory support. The objectives of this review are to describe the rationale of ECLS techniques, to review the pulmonary diseases potentially treated by ECLS, and finally to demonstrate the efficacy of ECLS, using recently published data from the literature, in order to practice evidence based medicine. STATE OF THE ART ECLS technologies should only be undertaken in expert centers. ECLS allows a protective ventilatory strategy in severe ARDS. In the field of lung transplantation, ECLS may be used successfully as a bridge to transplantation, as intraoperative cardiorespiratory support or as a bridge to recovery in cases of severe primary graft dysfunction. In general thoracic surgery, ECLS technology seems to be safe and efficient as intraoperative respiratory support for tracheobronchial surgery or for severe respiratory insufficiency, without significant increase in perioperative risk. PERSPECTIVE The indications for ECLS are going to increase. Future improvements both in scientific knowledge and bioengineering will improve the prognosis of patients treated with ECLS for respiratory failure. Multicenter randomized controlled trials will refine the indications for ECLS and improve the global care strategies for these patients. CONCLUSION ECLS is an efficient therapeutic strategy that will improve the prognosis of patients suffering from, or exposed to, the risks of severe respiratory failure.
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