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Balasubramanian P, Ghimire M, Pattnaik H, Saunders H, Franco PM, Sanghavi D, Patel NM, Baig H, Bhattacharyya A, Chaudhary S, Guru PK. Clinical Outcomes With Extracorporeal Membrane Oxygenation for Interstitial Lung Disease: Systematic Review and Meta-Analysis. ASAIO J 2024:00002480-990000000-00494. [PMID: 38810214 DOI: 10.1097/mat.0000000000002231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
The evidence on indications, outcomes, and complications with the use of extracorporeal membrane oxygenation (ECMO) in the setting of interstitial lung disease (ILD) is limited in the existing literature. We performed a systematic review and meta-analysis for the use of ECMO in the setting of ILD to study the prognostic factors associated with in-hospital mortality. Eighteen unique studies with a total of 1,356 patients on ECMO for ILD were identified out of which 76.5% were on ECMO as a bridge to transplant (BTT) and the rest as a bridge to recovery (BTR). The overall in-hospital mortality was 45.76%, with 71.3% and 37.8% for BTR and BTT, respectively. Among the various prognostic factors, mortality was lower with younger age (mean difference = 3.15, 95% confidence interval [CI] = 0.82-5.49), use of awake veno-arterial (VA)-ECMO compared to veno-venous (VV)-ECMO (unadjusted odds ratio [OR] = 0.22, 95% CI = 0.13-0.37) in the overall cohort. In the setting of BTT, the use of VA-ECMO had a decreased hazard ratio (HR) compared to VV-ECMO (adjusted HR = 0.34, 95% CI = 0.15-0.81, p = 0.015). The findings of our meta-analysis are critical but are derived from retrospective studies with small sample sizes and thus are of low to very low-GRADE certainty.
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Affiliation(s)
| | - Manoj Ghimire
- Department of Internal Medicine, Bronx Healthcare, Bronx, New York
| | | | - Hollie Saunders
- From the Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Devang Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Neal M Patel
- From the Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Hassan Baig
- From the Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Sanjay Chaudhary
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
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Rando HJ, Fanning JP, Cho SM, Kim BS, Whitman G, Bush EL, Keller SP. Extracorporeal membrane oxygenation as a bridge to lung transplantation: Practice patterns and patient outcomes. J Heart Lung Transplant 2024; 43:77-84. [PMID: 37394023 PMCID: PMC10756924 DOI: 10.1016/j.healun.2023.06.016] [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: 03/02/2023] [Revised: 05/02/2023] [Accepted: 06/25/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is increasingly relied on to bridge patients with respiratory failure to lung transplantation despite limited evidence for its use in this setting. This study evaluated longitudinal trends in practice patterns, patient characteristics, and outcomes in patients bridged with ECMO to lung transplant. METHODS A retrospective review of all adult isolated lung transplant patients in the United Network for Organ Sharing database between 2000 and 2019 was performed. Patients were classified as "ECMO" if supported with ECMO at the time of listing or transplantation and "non-ECMO" otherwise. Linear regression was used to evaluate trends in patient demographics during the study period. Trends in mortality were evaluated using Cox proportional hazards modeling, with time period as the primary covariate (2000-2004, 2005-2009, 2010-2014, or 2015-2019) and age, time on the waitlist, and underlying diagnosis as covariates. RESULTS The number of patients included were 40,866, of whom 1,387 (3.4%) were classified as ECMO and 39,479 (96.6%) as no ECMO. Average age and initial Lung Allocation Score increased significantly during the study period in both cohorts, but occurred at a slower rate in the ECMO population. The hazard of death was significantly lower in more recent years (2015-2019) for both the ECMO and non-ECMO cohorts (aHR (adjusted hazards ratio) 0.59, 95% confidence interval (CI) 0.37-0.96 and aHR 0.74, 95% CI 0.70-0.79) when compared to the early years (2000-2004) of the study period. CONCLUSIONS Post-transplantation survival for patients bridged to transplantation with ECMO demonstrates ongoing improvement despite cannulation of progressively older and sicker patients.
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Affiliation(s)
- Hannah J Rando
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland.
| | - Jonathon P Fanning
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Sung-Min Cho
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland; Division of Neuroscience Critical Care, Department of Neurology and Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Bo S Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Glenn Whitman
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Errol L Bush
- Division of General Thoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland; and the Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
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Neumann E, Sahli SD, Kaserer A, Braun J, Spahn MA, Aser R, Spahn DR, Wilhelm MJ. Predictors associated with mortality of veno-venous extracorporeal membrane oxygenation therapy. J Thorac Dis 2023; 15:2389-2401. [PMID: 37324096 PMCID: PMC10267924 DOI: 10.21037/jtd-22-1273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/10/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND The use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) has rapidly increased in recent years. Today, applications of V-V ECMO include a variety of clinical conditions such as acute respiratory distress syndrome (ARDS), bridge to lung transplantation and primary graft dysfunction after lung transplantation. The purpose of the present study was to investigate in-hospital mortality of adult patients undergoing V-V ECMO therapy and to determine independent predictors associated with mortality. METHODS This retrospective study was conducted at the University Hospital Zurich, a designated ECMO center in Switzerland. Data was analyzed of all adult V-V ECMO cases from 2007 to 2019. RESULTS In total, 221 patients required V-V ECMO support (median age 50 years, 38.9% female). In-hospital mortality was 37.6% and did not statistically vary significantly between indications (P=0.61): 25.0% (1/4) for primary graft dysfunction after lung transplantation, 29.4% (5/17) for bridge to lung transplantation, 36.2% (50/138) for ARDS and 43.5% (27/62) for other pulmonary disease indications. Cubic spline interpolation showed no effect of time on mortality over the study period of 13 years. Multiple logistic regression modelling identified significant predictor variables associated with mortality: age [odds ratio (OR), 1.05; 95% confidence interval (CI): 1.02-1.07; P=0.001], newly detected liver failure (OR, 4.83; 95% CI: 1.27-20.3; P=0.02), red blood cell transfusion (OR, 1.91; 95% CI: 1.39-2.74; P<0.001) and platelet concentrate transfusion (OR, 1.93; 95% CI: 1.28-3.15; P=0.004). CONCLUSIONS In-hospital mortality of patients receiving V-V ECMO therapy remains relatively high. Patients' outcomes have not improved significantly in the observed period. We identified age, newly detected liver failure, red blood cell transfusion and platelet concentrate transfusion as independent predictors associated with in-hospital mortality. Incorporating such mortality predictors into decision making with regards to V-V ECMO use may increase its effectiveness and safety and may translate into better outcomes.
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Affiliation(s)
- Elena Neumann
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Sebastian D. Sahli
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julia Braun
- Departments of Biostatistics and Epidemiology, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Muriel A. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Raed Aser
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Markus J. Wilhelm
- Clinic for Cardiac Surgery, University Heart Center, University and University Hospital Zurich, Zurich, Switzerland
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Mannem H, Aversa M, Keller T, Kapnadak SG. The Lung Transplant Candidate, Indications, Timing, and Selection Criteria. Clin Chest Med 2023; 44:15-33. [PMID: 36774161 DOI: 10.1016/j.ccm.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation can be lifesaving for patients with advanced lung disease. Demographics are evolving with recipients now sicker but determining candidacy remains predicated on one's underlying lung disease prognosis, along with the likelihood of posttransplant success. Determining optimal timing can be challenging, and most programs favor initiating the process early and proactively to allow time for patient education, informed decision-making, and preparation. A comprehensive, multidisciplinary evaluation is used to elucidate disease progrnosis and identify risk factors for poor posttransplant outcomes. Candidacy criteria vary significantly by center, and close communication between referring and transplant providers is necessary to improve access to transplant and outcomes.
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Affiliation(s)
- Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, University of Virginia School of Medicine, PO Box 800546, Clinical Department Wing, 1 Hospital Drive, Charlottesville, VA 22908, USA
| | - Meghan Aversa
- Division of Respirology, Department of Medicine, University Health Network and University of Toronto, C. David Naylor Building, 6 Queen's Park Crescent West, Third Floor, Toronto, ON M5S 3H2, Canada
| | - Thomas Keller
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Campus Box 356522, Seattle, WA 98195, USA
| | - Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington School of Medicine, 1959 Northeast Pacific Street, Campus Box 356522, Seattle, WA 98195, USA.
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Cantu E, Diamond JM, Cevasco M, Suzuki Y, Crespo M, Clausen E, Dallara L, Ramon CV, Harmon MT, Bermudez C, Benvenuto L, Anderson M, Wille KM, Weinacker A, Dhillon GS, Orens J, Shah P, Merlo C, Lama V, McDyer J, Snyder L, Palmer S, Hartwig M, Hage CA, Singer J, Calfee C, Kukreja J, Greenland JR, Ware LB, Localio R, Hsu J, Gallop R, Christie JD. Contemporary trends in PGD incidence, outcomes, and therapies. J Heart Lung Transplant 2022; 41:1839-1849. [PMID: 36216694 PMCID: PMC9990084 DOI: 10.1016/j.healun.2022.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We sought to describe trends in extracorporeal membrane oxygenation (ECMO) use, and define the impact on PGD incidence and early mortality in lung transplantation. METHODS Patients were enrolled from August 2011 to June 2018 at 10 transplant centers in the multi-center Lung Transplant Outcomes Group prospective cohort study. PGD was defined as Grade 3 at 48 or 72 hours, based on the 2016 PGD ISHLT guidelines. Logistic regression and survival models were used to contrast between group effects for event (i.e., PGD and Death) and time-to-event (i.e., death, extubation, discharge) outcomes respectively. Both modeling frameworks accommodate the inclusion of potential confounders. RESULTS A total of 1,528 subjects were enrolled with a 25.7% incidence of PGD. Annual PGD incidence (14.3%-38.2%, p = .0002), median LAS (38.0-47.7 p = .009) and the use of ECMO salvage for PGD (5.7%-20.9%, p = .007) increased over the course of the study. PGD was associated with increased 1 year mortality (OR 1.7 [95% C.I. 1.2, 2.3], p = .0001). Bridging strategies were not associated with increased mortality compared to non-bridged patients (p = .66); however, salvage ECMO for PGD was significantly associated with increased mortality (OR 1.9 [1.3, 2.7], p = .0007). Restricted mean survival time comparison at 1-year demonstrated 84.1 days lost in venoarterial salvaged recipients with PGD when compared to those without PGD (ratio 1.3 [1.1, 1.5]) and 27.2 days for venovenous with PGD (ratio 1.1 [1.0, 1.4]). CONCLUSIONS PGD incidence continues to rise in modern transplant practice paralleled by significant increases in recipient severity of illness. Bridging strategies have increased but did not affect PGD incidence or mortality. PGD remains highly associated with mortality and is increasingly treated with salvage ECMO.
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Affiliation(s)
- Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yoshi Suzuki
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Dallara
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian V Ramon
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael T Harmon
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Michaela Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Keith M Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ann Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Gundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Jonathan Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Christian Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Vibha Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
| | - John McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Laurie Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Scott Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matt Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chadi A Hage
- Division of Pulmonary, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan Singer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, California
| | - Carolyn Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Russel Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Patterson CM, Shah A, Rabin J, DiChiacchio L, Cypel M, Hoetzenecker K, Catarino P, Lau CL. EXTRACORPOREAL LIFE SUPPORT AS A BRIDGE TO LUNG TRANSPLANTATION: WHERE ARE WE NOW? J Heart Lung Transplant 2022; 41:1547-1555. [DOI: 10.1016/j.healun.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/21/2022] [Accepted: 06/05/2022] [Indexed: 11/16/2022] Open
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Soder SA, Fontena E, Salgado JC, Shahmohammadi A, Samano MN, Machuca TN. Inpatient Management of the Acutely Decompensating Lung Transplant Candidate. Thorac Surg Clin 2022; 32:121-134. [PMID: 35512931 DOI: 10.1016/j.thorsurg.2022.02.001] [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: 11/25/2022]
Abstract
Lung allocation in the US changed nearly 15 years ago from time accrued on the waiting list to disease severity and likelihood of posttransplant survival, represented by the lung allocation score (LAS). Notably, the risk of death within a year plays a stronger role on the score calculation than posttransplant survival. While this change was associated with the intended decrease in waitlist mortality (most recently reported at 14.6%), it was predictable that transplant teams would have to care for increasingly older and complex candidates and recipients. This urgency-based allocation also led centers to routinely consider transplanting patients with higher acuity, often hospitalized and, not infrequently, in the intensive care unit (ICU). According to the Scientific Registry for Transplant Recipients, from 2009 to 2019, the proportion of lung recipients hospitalized and those admitted to the ICU at the time of transplant increased from 18.9% to 26.8% and from 9.2% to 16.5%, respectively..
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Affiliation(s)
- Stephan A Soder
- Division of Thoracic Surgery and Lung Transplant Program, Irmandade da Santa Casa de Misericordia de Porto Alegre. 295, Professor Annes Dias Street. Hospital Dom Vicente Scherer, 6th Floor. Centro Histórico. Porto Alegre, Rio Grande do Sul 90020-090, Brazil
| | - Eduardo Fontena
- Lung Transplant Program, Hospital COPA D'Or, Rede D'Or Sao Luiz. 598, Figueiredo Magalhães Street. Room 39. Rio de Janeiro, Rio de Janeiro 22031-012, Brazil
| | - Juan C Salgado
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street. Gates Pavilion 9036. Philadelphia, PA 19104, USA
| | - Abbas Shahmohammadi
- Lung Transplant and ECMO Program, University of Florida Division of Pulmonary, Critical Care and Sleep Medicine 1600 SW Archer Road, Room M452 Gainesville, FL 32610-0225, USA
| | - Marcos N Samano
- Lung Transplant Program, Hospital Israelita Albert Einstein, Sao Paulo, Brazil. Av. Albert Eintein, 627, Bloco A1, sala 418 Sao Paulo, Sao Paulo 05652-900, Brazil; Division of Thoracic Surgery, University of Sao Paulo, Sao Paulo, Brazil. Av. Dr. Eneas Carvalho Aguiar, 44, Sao Paulo, São Paulo 05403-900, Brazil
| | - Tiago N Machuca
- Division of Thoracic Surgery, UF Lung Transplant Program, Adult ECMO, University of Florida, PO Box 100129, Gainesville, FL 32610-0129, USA.
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Lee SH. Awakening in extracorporeal membrane oxygenation as a bridge to lung transplantation. Acute Crit Care 2022; 37:26-34. [PMID: 35279976 PMCID: PMC8918718 DOI: 10.4266/acc.2022.00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/12/2022] [Indexed: 12/01/2022] Open
Abstract
Although the rate of lung transplantation (LTx), the last treatment option for end-stage lung disease, is increasing, some patients waiting for LTx need a bridging strategy for LTx due to the limited number of available donor lungs. For a long time, mechanical ventilation has been employed as a bridge to LTx because the outcome of using extracorporeal membrane oxygenation (ECMO) as a bridging strategy has been poor. However, the outcome after mechanical ventilation as a bridge to LTx was poor compared with that in patients without bridges. With advances in technology and the accumulation of experience, the outcome of ECMO as a bridge to LTx has improved, and the rate of ECMO use as a bridging strategy has increased over time. However, whether the use of ECMO as a bridge to LTx can achieve survival rates similar to those of non-bridged LTx patients remains controversial. In 2010, one center introduced awake ECMO strategy for LTx bridging, and its use as a bridge to LTx has been showing favorable outcomes to date. Awake ECMO has several advantages, such as maintenance of physical activity, spontaneous breathing, avoidance of endotracheal intubation, and reduced use of sedatives and analgesics, but it may cause serious problems. Nonetheless, several studies have shown that awake ECMO performed by a multidisciplinary team is safe. In cases where ECMO or mechanical ventilation is required due to unavoidable exacerbation in patients awaiting LTx, the application of awake ECMO performed by an appropriately trained ECMO multi-disciplinary team can be useful.
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Sef D, Verzelloni Sef A, Trkulja V, Raj B, Lees NJ, Walker C, Mitchell J, Petrou M, De Robertis F, Stock U, McGovern I. Midterm outcomes of venovenous extracorporeal membrane oxygenation as a bridge to lung transplantation: Comparison with nonbridged recipients. J Card Surg 2022; 37:747-759. [PMID: 35060184 DOI: 10.1111/jocs.16253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/28/2021] [Accepted: 12/24/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Davorin Sef
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Alessandra Verzelloni Sef
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Vladimir Trkulja
- Department of Pharmacology Zagreb University School of Medicine Zagreb Croatia
| | - Binu Raj
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Nicholas J. Lees
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Christopher Walker
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Jerry Mitchell
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Mario Petrou
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Fabio De Robertis
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Ulrich Stock
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Ian McGovern
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
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Kim NE, Woo A, Kim SY, Leem AY, Park Y, Kwak SH, Yong SH, Chung K, Park MS, Kim YS, Kim HE, Lee JG, Paik HC, Lee SH. Long- and short-term clinical impact of awake extracorporeal membrane oxygenation as bridging therapy for lung transplantation. Respir Res 2021; 22:306. [PMID: 34839821 PMCID: PMC8627606 DOI: 10.1186/s12931-021-01905-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background As lung transplantation (LTx) is becoming a standard treatment for end-stage lung disease, the use of bridging with extracorporeal membrane oxygenation (ECMO) is increasing. We examined the clinical impact of being awake during ECMO as bridging therapy in patients awaiting LTx.
Methods In this single-center study, we retrospectively reviewed 241 consecutive LTx patients between October 2012 and March 2019; 64 patients received ECMO support while awaiting LTx. We divided into awake and non-awake groups and compared. Results Twenty-five patients (39.1%) were awake, and 39 (61.0%) were non-awake. The median age of awake patients was 59.0 (interquartile range, 52.5–63.0) years, and 80% of the group was men. The awake group had better post-operative outcomes than the non-awake group: statistically shorter post-operative intensive care unit length of stay [awake vs. non-awake, 6 (4–8.5) vs. 18 (11–36), p < 0.001], longer ventilator free days [awake vs. non-awake, 24 (17–26) vs. 0 (0–15), p < 0.001], and higher gait ability after LTx (awake vs. non-awake, 92% vs. 59%, p = 0.004), leading to higher 6-month and 1-year lung function (forced expiratory volume in 1 s: awake vs. non-awake, 6-month, 77.5% vs. 61%, p = 0.004, 1-year, 75% vs. 57%, p = 0.013). Furthermore, the awake group had significantly lower 6-month and 1-year mortality rates than the non-awake group (6-month 12% vs. 38.5%, p = 0.022, 1-year 24% vs. 53.8%, p = 0.018). Conclusions In patients with end-stage lung disease, considering the long-term and short-term impacts, the awake ECMO strategy could be useful compared with the non-awake ECMO strategy. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01905-7.
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Affiliation(s)
- Nam Eun Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Womans University College of Medicine, Ewha Womans Seoul Hospital, Seoul, South Korea
| | - Ala Woo
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Song Yee Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Ah Young Leem
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Youngmok Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Se Hyun Kwak
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Seung Hyun Yong
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Kyungsoo Chung
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Moo Suk Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Young Sam Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Ha Eun Kim
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Su Hwan Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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11
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Kapnadak SG, Raghu G. Lung transplantation for interstitial lung disease. Eur Respir Rev 2021; 30:30/161/210017. [PMID: 34348979 DOI: 10.1183/16000617.0017-2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/02/2021] [Indexed: 01/18/2023] Open
Abstract
Lung transplantation (LTx) can be a life-extending treatment option for patients with advanced and/or progressive fibrotic interstitial lung disease (ILD), especially idiopathic pulmonary fibrosis (IPF), fibrotic hypersensitivity pneumonitis, sarcoidosis and connective tissue disease-associated ILD. IPF is now the most common indication for LTx worldwide. Several unique features in patients with ILD can impact optimal timing of referral or listing for LTx, pre- or post-transplant risks, candidacy and post-transplant management. As the epidemiology of LTx and community practices have evolved, recent literature describes outcomes and approaches in higher-risk candidates. In this review, we discuss the unique and important clinical findings, course, monitoring and management of patients with IPF and other progressive fibrotic ILDs during pre-LTx evaluation and up to the day of transplantation; the need for co-management with clinical experts in ILD and LTx is emphasised. Some post-LTx complications are unique in these patient cohorts, which require prompt detection and appropriate management by experts in multiple disciplines familiar with telomere biology disorders and infectious, haematological, oncological and cardiac complications to enhance the likelihood of improved outcomes and survival of LTx recipients with IPF and other ILDs.
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Affiliation(s)
- Siddhartha G Kapnadak
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, University of Washington, Seattle, WA, USA .,Dept of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
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12
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Nasir BS, Klapper J, Hartwig M. Lung Transplant from ECMO: Current Results and Predictors of Post-transplant Mortality. CURRENT TRANSPLANTATION REPORTS 2021; 8:140-150. [PMID: 33842193 PMCID: PMC8021937 DOI: 10.1007/s40472-021-00323-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 01/22/2023]
Abstract
Purpose of Review We examined data from the last 5 years describing extracorporeal life support (ECLS) as a bridge to lung transplantation. We assessed predictors of survival to transplantation and post-transplant mortality. Recent Findings The number of lung transplants performed worldwide is increasing. This is accompanied by an increase in the type of patients being transplanted, including sicker patients with more advanced disease. Consequently, there is an increase in the need for bridging strategies, with varying success. Several predictors of failure have been identified. Major risk factors include retransplantation, other organ dysfunction, and deconditioning. Summary ECLS is a risky strategy but necessary for patients who would otherwise die if not bridged to transplantation. The presence of predictors for failure is not a contraindication for bridging. However, major risk factors should be approached cautiously. Other, more minor risk factors may be considered acceptable. More importantly, the strategy should be individualized for each patient to achieve the best possible outcomes.
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Affiliation(s)
- Basil S Nasir
- Division of Thoracic Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, 1000 rue Saint-Denis, Montreal, Quebec, H2X 0C1 Canada
| | - Jacob Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke Medical Center, Durham, NC USA
| | - Matthew Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke Medical Center, Durham, NC USA
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13
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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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14
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Kapnadak SG, Ramos KJ, Dellon EP. Enhancing care for individuals with advanced cystic fibrosis lung disease. Pediatr Pulmonol 2021; 56 Suppl 1:S69-S78. [PMID: 32609949 DOI: 10.1002/ppul.24937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 11/09/2022]
Abstract
While remarkable advances in cystic fibrosis (CF) care have led to improvements in survival and quality of life, many individuals with CF are living with advanced cystic fibrosis lung disease (ACFLD) and others will face continued disease progression and its associated complex treatments and choices. This review will provide a summary of recently published guidelines for ACFLD care and lung transplant referral and highlight ongoing work to enhance the care of those with ACFLD through improvements in medical and psychosocial care, palliative care, and care around lung transplantation.
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Affiliation(s)
- Siddhartha G Kapnadak
- Division of Pulmonary, Department of Medicine, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Kathleen J Ramos
- Division of Pulmonary, Department of Medicine, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Elisabeth P Dellon
- Division of Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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15
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Abstract
Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.
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Affiliation(s)
- Ilhan Inci
- Department of Thoracic Surgery, University Hospital, Raemistrasse, Zurich, Switzerland
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16
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Lung transplantation for cystic fibrosis. J Heart Lung Transplant 2020; 39:553-560. [PMID: 32147452 DOI: 10.1016/j.healun.2020.02.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The contribution of lung transplantation to the treatment of patients with end-stage cystic fibrosis (CF) has been debated. We aimed to describe achievable outcomes from high-volume CF and lung transplant programs. This study reports on the largest single-center experience of lung transplantation for adult and pediatric patients with CF. It also highlights the evolution of practice and outcomes over time. METHODS A retrospective analysis of the prospectively collected Toronto Lung Transplant database was carried out. Post-transplant survival in CF was calculated using the Kaplan-Meier method and analyzed with log-rank tests. RESULTS From 1983 to 2016, a total of 1,885 transplants were performed at our institution, where 364 (19.3%) were CF recipients and another 39 (2.1%) were CF retransplants. The mean age at first transplant was 29.5 ± 9.7 years where 56.6% were males and 91.5% were adults. Pre-transplantation, 88 patients (24.2%) were Burkholderia cepacia complex (BCC)-positive, 143 (39.3%) had diabetes mellitus, and the mean forced expiratory volume in one second was 26.0 ± 7.2%, as predicted at listing. The 1-, 5-, and 10-year probabilities of survival in adults who were BCC-negative were 94%, 70%, and 53%, respectively. Pediatric, BCC-positive, and retransplant recipients had worse survival than adult patients who were BCC-negative. Strategies to improve the donor pool did not affect survival but possibly reduced waitlist mortality. For the entire cohort, the most common causes of death after lung transplant were infection and chronic lung allograft dysfunction. CONCLUSIONS Lung transplantation for CF provides excellent short- and long-term outcomes. These results strongly support lung transplantation as the standard of care for patients with CF having advanced lung disease.
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17
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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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18
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Hayanga JA, Hayanga HK, Holmes SD, Ren Y, Shigemura N, Badhwar V, Abbas G. Mechanical ventilation and extracorporeal membrane oxygenation as a bridge to lung transplantation: Closing the gap. J Heart Lung Transplant 2019; 38:1104-1111. [DOI: 10.1016/j.healun.2019.06.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 06/05/2019] [Accepted: 06/28/2019] [Indexed: 11/26/2022] Open
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19
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Improving Outcomes in Bridge-to-Transplant: Extended Extracorporeal Membrane Oxygenation Support to Obtain Optimal Donor Lungs for Marginal Recipients. ASAIO J 2019; 65:516-521. [DOI: 10.1097/mat.0000000000000843] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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20
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Nam KH, Koh Y, Lim CM, Huh JW, Jung SH, Kang PJ, Lim JY, Hong SB. Central Extracorporeal Membrane Oxygenation for Bridging of Right-Sided Heart Failure to Lung Transplantation: A Single-Center Experience and Literature Review. J Cardiothorac Vasc Anesth 2019; 33:1873-1876. [DOI: 10.1053/j.jvca.2019.01.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 01/23/2019] [Accepted: 01/25/2019] [Indexed: 01/30/2023]
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21
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Yanagida R, Seethamraju H, Davenport DL, Tribble TA, Zwischenberger JB, Hoopes CW. Bridging to lung transplantation with double-lumen venovenous extracorporeal membrane oxygenation. Int J Artif Organs 2019; 42:621-627. [PMID: 31151368 DOI: 10.1177/0391398819851516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Double-lumen venovenous extracorporeal membrane oxygenation may be used as a bridge to lung transplantation. Predictors of outcome with this strategy have not been well described. METHODS All patients with irreversible lung disease who developed acute pulmonary failure and required double-lumen venovenous extracorporeal membrane oxygenation as a bridge to decision or lung transplant at our institution were included in this study. Survival of the extracorporeal membrane oxygenation patients was compared with listed patients who did not require extracorporeal membrane oxygenation with lung allocation score in the highest 10% for the same period. RESULTS Fifteen patients (46 ± 17 years old) received double-lumen venovenous extracorporeal membrane oxygenation cannula. Mean length of extracorporeal membrane oxygenation support was 18.2 (1-60) days. Of these, seven patients were bridged to lung transplant, six died on extracorporeal membrane oxygenation, and two weaned to recovery. Amount of red blood cell transfusion was significantly higher (3.3 vs 18.5 U, p = 0.003) and lowest oxygen saturation was significantly lower in non-survivors (84.5% vs 66.3%, p = 0.002). Of the seven patients who were already listed for lung transplant at the onset of extracorporeal membrane oxygenation, five were transplanted. Overall survival to hospital discharge was 60%. Survival of patients with lung allocation score in the highest 10% (average lung allocation score 83.4) in the same period was 80%. CONCLUSION Double-lumen venovenous extracorporeal membrane oxygenation cannula is a feasible option to bridge patients to decision or lung transplantation. Blood transfusion requirement and low oxygen saturation are markers of poor prognosis. Listing status at the time of cannulation and ambulation during extracorporeal membrane oxygenation support may be important indicators of good outcome.
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Affiliation(s)
- Roh Yanagida
- Department of Cardiothoracic Surgery, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Harish Seethamraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Newark Beth Israel Medical Center, Newark, NJ, USA
| | | | - Thomas A Tribble
- Department of Surgery, University of Kentucky, Lexington, KY, USA
| | | | - Charles W Hoopes
- Department of Cardiothoracic Surgery, The University of Alabama, Tuscaloosa, AL, USA
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22
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Abstract
Lung transplantation is the gold standard for treating patients with end-stage lung disease. Such patients can present with severe illness on the waitlist and may deteriorate before a lung donor is available. Bridging strategies with extracorporeal membrane oxygenation (ECMO) are valuable for getting patients to transplant and provide a chance at survival. The current article describes the indications, contraindications, and techniques involved in bridging to lung transplantation with ECMO.
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Affiliation(s)
- Aladdein Mattar
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, One Baylor Plaza, 11C33, Houston, TX 77030, USA
| | - Subhasis Chatterjee
- Thoracic Surgical ICU, ECMO Program, Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, CHI Baylor St. Lukes, Neurosensory Center, Mailstop BCM 390, Suite NC100T, 6501 Fannin Street, Houston, TX 77030, USA
| | - Gabriel Loor
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Baylor St Luke's Medical Center, Baylor College of Medicine, 6770 Bertner Avenue, Suite C-355K, Houston, TX 77030, USA.
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23
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Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation in the United States: A Multicenter Survey. ASAIO J 2019; 64:689-693. [PMID: 29251631 DOI: 10.1097/mat.0000000000000731] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The clinical use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LTx) has greatly increased in recent years. However, clinical practices for ECMO as a bridge to LTx vary widely between LTx centers. To better define the current practice of ECMO as a bridge to LTx, we surveyed pre-LTx ECMO practices among all adult LTx programs in the United States. All US LTx centers were surveyed (n = 57) between January and December 2014. Responses were received from 33 of 57 centers (58%). Of 33 responding centers, six (18%) performed ≥50 LTxs per year (defined as high volume) and two (6%) performed <10 LTxs per year (low volume). Two-third of responding centers, 22/33 (67%), reported use of ECMO as a bridge to LTx. Of these 22 centers, 18 (82%) successfully used venovenous (VV) ECMO as a bridge to LTx using the dual-lumen Avalon cannula. Patient >65 years of age was judged an ECMO contraindication in 15/33 (45%) of responding centers, but 12/33 (36%) centers, including the six high-volume centers, had no official age cutoff for ECMO candidacy. There was no consensus on the maximum acceptable duration of pre-LTx ECMO therapy; although 18/33 (55%) of programs had no defined maximal duration of ECMO pre-LTx, 10/33 (30%) considered >10 days on ECMO support contraindicated. Our survey suggests that in the United States, ECMO is used frequently pre-LTx, particularly VV ECMO at high-volume centers. However, criteria for ECMO initiation, age eligibility, bedside care, and maximum duration of support varied significantly between survey respondents.
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24
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Benazzo A, Schwarz S, Frommlet F, Schweiger T, Jaksch P, Schellongowski P, Staudinger T, Klepetko W, Lang G, Hoetzenecker K. Twenty-year experience with extracorporeal life support as bridge to lung transplantation. J Thorac Cardiovasc Surg 2019; 157:2515-2525.e10. [PMID: 30922636 DOI: 10.1016/j.jtcvs.2019.02.048] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 01/21/2019] [Accepted: 02/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Extracorporeal life support is increasingly used to bridge deteriorating candidates to lung transplantation. Nevertheless, only few systematic reports with a limited number of patients exist describing this practice and its changes over time. METHODS We retrospectively reviewed our institutional database and performed an era analysis to identify trends over time and risk factors for mortality. After applying propensity score matching, outcomes of bridged patients were compared with those of standard lung transplantation recipients. RESULTS Extracorporeal life support was used in 120 patients as an intention to bridge to lung transplantation. Eleven patients (9.2%) were bridged between 1998 and 2004, 39 patients (32.5%) were bridged between 2005 and 2010, and 70 patients were bridged (58.3%) between 2010 and 2017. In the first era, the main bridging modality was venoarterial-extracorporeal membrane oxygenation (n = 10, 90.9%), whereas venovenous devices were primarily used in later eras (second era: n = 18, 46.2%; third era: n = 39, 55.8%). In the second and third eras, 9 patients (23.1%) and 24 patients (34.3%) could be bridged awake. Short-term outcome was poor in the first era, with only 36.4% of patients discharged alive but improved in later eras (53.8% and 77.1%; P = .002). Extracorporeal life support-bridged patients showed an impaired short-term outcome compared with standard recipients. However, survival conditional on 90 days did not differ among the groups (P = .178). In univariate and multivariate analyses, awake extracorporeal life support was protective for survival, whereas acute retransplantation was a risk factor for mortality. CONCLUSIONS Over the past 2 decades, the role of extracorporeal life support bridging evolved from an acute rescue therapy to a semi-elective procedure. Stratified outcome analysis revealed that extracorporeal life support bridging yielded similar long-term survival compared with nonbridged patients.
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Affiliation(s)
- Alberto Benazzo
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Schwarz
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Florian Frommlet
- Institute for Medical Statistics, CEMSII, Medical University of Vienna, Vienna, Austria
| | - Thomas Schweiger
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Jaksch
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Peter Schellongowski
- Division of Intensive Care Unit, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Thomas Staudinger
- Division of Intensive Care Unit, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Walter Klepetko
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - György Lang
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria; Department of Thoracic Surgery, Semmlweis University and National Institute for Oncology, Budapest, Hungary
| | - Konrad Hoetzenecker
- Division of Thoracic Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.
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25
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Tipograf Y, Salna M, Minko E, Grogan EL, Agerstrand C, Sonett J, Brodie D, Bacchetta M. Outcomes of Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation. Ann Thorac Surg 2019; 107:1456-1463. [PMID: 30790550 DOI: 10.1016/j.athoracsur.2019.01.032] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/17/2018] [Accepted: 01/03/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) has become a critical component of caring for patients with end-stage lung disease. This study examined outcomes of patients who received ECMO as a BTT. METHODS Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients who received ECMO as BTT at Columbia University Medical Center from April 2009 through July 2018. RESULTS A total of 121 adult patients were placed on ECMO as BTT, and 70 patients (59%) were successfully bridged to lung transplantation. Simplified Acute Physiology Score II, unplanned endotracheal intubation, renal replacement therapy, and cerebrovascular accident were identified as independent predictors of unsuccessful BTT. Ambulation was the only independent predictor of successful BTT (odds ratio, 7.579; 95% confidence interval, 2.158 to 26.615; p = 0.002). Among the 64 patients (91%) who survived to hospital discharge, survival was 88% at 1 year and 83% at 3 years. Propensity matching between BTT and non-BTT lung transplant recipients did not show a significant difference in survival (log-rank = 0.53) despite significant differences in the lung allocation score (median, 92.2 [interquartile range, 89.0 to 94.2] vs 49.6 [interquartile range, 40.6 to 72.3], p < 0.01). CONCLUSIONS ECMO can be used successfully to bridge patients with end-stage lung disease to lung transplantation. When implemented by an experienced team with adherence to stringent protocols and patient selection, outcomes in BTT patients were comparable to patients who did not receive pretransplant support.
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Affiliation(s)
- Yuliya Tipograf
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Salna
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Elizaveta Minko
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Eric L Grogan
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cara Agerstrand
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Joshua Sonett
- Section of Thoracic Surgery, Department of Surgery, Columbia Medical Center, New York, New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
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26
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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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Ratnani I, Tuazon D, Zainab A, Uddin F. The Role and Impact of Extracorporeal Membrane Oxygenation in Critical Care. Methodist Debakey Cardiovasc J 2018; 14:110-119. [PMID: 29977467 DOI: 10.14797/mdcj-14-2-110] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Use of extracorporeal membrane oxygenation (ECMO) has been exponentially increasing over the last decade and is now considered a mainstream lifesaving treatment modality in critical care medicine. However, the need for physician education, training, and experience remains imperative. Although ECMO has traditionally been used in end-stage lung disease and circulatory collapse, it is being adopted for use in right heart failure, as a bridge to heart and lung transplantation, and as rescue therapy for both sepsis and post-organ transplantation. The following article discusses indications, management, complications, and challenges of ECMO as well as our experience at the Houston Methodist DeBakey Heart & Vascular Center.
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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: 29] [Impact Index Per Article: 4.8] [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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Chicotka S, Pedroso FE, Agerstrand CL, Rosenzweig EB, Abrams D, Benson T, Layton A, Burkhoff D, Brodie D, Bacchetta MD. Increasing Opportunity for Lung Transplant in Interstitial Lung Disease With Pulmonary Hypertension. Ann Thorac Surg 2018; 106:1812-1819. [PMID: 29852149 DOI: 10.1016/j.athoracsur.2018.04.068] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 03/24/2018] [Accepted: 04/23/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation for end-stage interstitial lung disease (ILD) and pulmonary hypertension (PH) has varying results based on ECMO configuration. We compare our experience using venovenous (VV) and venoarterial (VA) ECMO bridge to transplantation for ILD with PH on survival to successful transplantation. METHODS A single-center retrospective review was done of patients with ILD and secondary PH who were placed on either VV or VA ECMO as bridge to transplantation from 2010 to 2016. Comparisons for factors associated with survival to transplantation between VV and VA ECMO strategies were made using Cox proportional hazards model. Subgroup analysis included comparisons of VV ECMO patients who remained on VV or were converted to VA ECMO. RESULTS A total of 50 patients with ILD and PH were treated initially with either VV (n = 19) or VA (n = 31) ECMO as bridge to lung transplantation. Initial VA ECMO had a significantly higher survival to transplantation compared with initial VV ECMO (p = 0.03). Cox proportional hazards modeling showed a 59% reduction in risk of death for VA compared with VV ECMO (hazard reduction 0.41, 95% confidence interval: 0.18 to 0.92, p = 0.03). Patients converted from VV to VA ECMO had significantly longer survival awaiting transplant than patients who remained on VV ECMO (p = 0.03). Ambulation on ECMO before transplantation was associated with an 80% reduction in the risk of death (hazard reduction 0.20, 95% confidence interval: 0.08 to 0.48, p < 0.01). CONCLUSIONS Venoarterial ECMO upper body configuration for patients with end stage ILD and PH significantly improves overall survival to transplantation.
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Affiliation(s)
- Scott Chicotka
- Section of Thoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Felipe E Pedroso
- Section of Thoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Cara L Agerstrand
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Erika B Rosenzweig
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Darryl Abrams
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Tom Benson
- Department of Physical Therapy, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital Columbia Campus, New York, New York
| | - Aimee Layton
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Daniel Burkhoff
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital Columbia Campus, New York, New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York
| | - Matthew D Bacchetta
- Section of Thoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York.
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Hakim AH, Ahmad U, McCurry KR, Johnston DR, Pettersson GB, Budev M, Murthy S, Blackstone EH, Tong MZ. Contemporary Outcomes of Extracorporeal Membrane Oxygenation Used as Bridge to Lung Transplantation. Ann Thorac Surg 2018; 106:192-198. [PMID: 29559375 DOI: 10.1016/j.athoracsur.2018.02.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 02/05/2018] [Accepted: 02/12/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO), when used as bridge to lung transplantation, (BTT) identifies high-risk candidates. Recent advances in cannula design and patient selection fosters "awake ambulatory ECMO" as a viable option for critically ill candidates in an attempt to retard deconditioning while awaiting allografts. METHODS From 2012 to 2015, 30 patients underwent ECMO as BTT. Candidacy for ECMO was determined before listing for transplant. A dual-lumen single cannula was used first in 13 of 30 patients (43%). Of the remaining 30 patients, 6 (20%) were supported with venoarterial ECMO and 11 (37%) with venovenous ECMO, with double-site cannulation in 11 (37%), and 6 of 11 converted to a dual-lumen single cannula. All ECMO patients were managed in a dedicated heart/lung failure intensive care unit, and early aggressive physical therapy, ambulation, and spontaneous breathing trials were emphasized. RESULTS BTT was successful in 26 patients (87%). In the 19 patients with dual-lumen single cannula, 5 (26%) were successfully ambulated, and 6 (32%) achieved spontaneous ventilation. Median (25th, 75th percentile) lengths of stay in the intensive care unit and hospital were 33 days (20, 46 days) and 56 days (28, 78 days), respectively, and were 20 and 31 days, respectively, in patients successfully ambulated (intensive care unit: p = 0.5; hospital: p = 0.4). Among all patients who received a transplant, 30-day, 1-year, and 3-year survival were 92%, 85%, and 80%, respectively. Among patients undergoing primary transplants, 3-year survival was 91%. CONCLUSIONS ECMO as BTT has led to encouraging perioperative outcomes and early survival. Careful patient selection and early use of ECMO seems to allow for preservation of vitality while these critically ill candidates await donor organs, which may improve outcomes.
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Affiliation(s)
- Ali H Hakim
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Usman Ahmad
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gosta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio; Transplantation Center, Cleveland Clinic Foundation, Cleveland, Ohio; Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Marie Budev
- Transplantation Center, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Pulmonary Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio; Transplantation Center, Cleveland Clinic Foundation, Cleveland, Ohio; Department of Qualitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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Castellani C, Duff AJA, Bell SC, Heijerman HGM, Munck A, Ratjen F, Sermet-Gaudelus I, Southern KW, Barben J, Flume PA, Hodková P, Kashirskaya N, Kirszenbaum MN, Madge S, Oxley H, Plant B, Schwarzenberg SJ, Smyth AR, Taccetti G, Wagner TOF, Wolfe SP, Drevinek P. ECFS best practice guidelines: the 2018 revision. J Cyst Fibros 2018; 17:153-178. [PMID: 29506920 DOI: 10.1016/j.jcf.2018.02.006] [Citation(s) in RCA: 432] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/26/2018] [Accepted: 02/08/2018] [Indexed: 12/12/2022]
Abstract
Developments in managing CF continue to drive dramatic improvements in survival. As newborn screening rolls-out across Europe, CF centres are increasingly caring for cohorts of patients who have minimal lung disease on diagnosis. With the introduction of mutation-specific therapies and the prospect of truly personalised medicine, patients have the potential to enjoy good quality of life in adulthood with ever-increasing life expectancy. The landmark Standards of Care published in 2005 set out what high quality CF care is and how it can be delivered throughout Europe. This underwent a fundamental re-write in 2014, resulting in three documents; center framework, quality management and best practice guidelines. This document is a revision of the latter, updating standards for best practice in key aspects of CF care, in the context of a fast-moving and dynamic field. In continuing to give a broad overview of the standards expected for newborn screening, diagnosis, preventative treatment of lung disease, nutrition, complications, transplant/end of life care and psychological support, this consensus on best practice is expected to prove useful to clinical teams both in countries where CF care is developing and those with established CF centres. The document is an ECFS product and endorsed by the CF Network in ERN LUNG and CF Europe.
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Affiliation(s)
- Carlo Castellani
- Cystic Fibrosis Centre, Azienda Ospedaliera Universitaria Integrata Verona, Italy; Cystic Fibrosis Centre, Gaslini Institute, Genoa, Italy
| | - Alistair J A Duff
- Regional Paediatric CF Unit, Leeds General Infirmary Leeds, UK; Department of Clinical & Health Psychology, St James' University Hospital, Leeds, UK.
| | - Scott C Bell
- Adult Cystic Fibrosis Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Harry G M Heijerman
- Dept of Pulmonology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Munck
- Hopital Robert Debré Assistante publique-Hôpitaux de Paris, Université Paris 7, Pediatric CF Centre, Paris, France
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Canada
| | - Isabelle Sermet-Gaudelus
- Service de Pneumologie et Allergologie Pédiatriques, Centre de Ressources et de Compétence de la Mucoviscidose, Institut Necker Enfants Malades/INSERM U1151 Hôpital Necker Enfants Malades, P, France
| | - Kevin W Southern
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Jurg Barben
- Ostschweizer Kinderspital Sankt Gallen, Claudiusstrasse 6, 9006 St. Gallen, Switzerland
| | - Patrick A Flume
- Division of Pulmonary and Critical Care, Medical University of South Carolina, USA
| | - Pavla Hodková
- Department of Clinical Psychology, University Hospital, Prague, Czech Republic
| | - Nataliya Kashirskaya
- Department of Genetic Epidemiology (Cystic Fibrosis Group), Federal State Budgetary Institution, Research Centre for Medical Genetics, Moscow, Russia
| | - Maya N Kirszenbaum
- Department of Pediatric Pulmunology, CRCM, Hôpital Necker-Enfants Malades, Paris, France
| | - Sue Madge
- Cystic Fibrosis Centre, Royal Brompton Hospital, London, UK
| | - Helen Oxley
- Manchester Adult Cystic Fibrosis Centre, University Hospital of South Manchester NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Barry Plant
- Cork Adult CF Centre, Cork University Hospital, University College, Cork, Republic of Ireland
| | - Sarah Jane Schwarzenberg
- Divison of Pediatric Gastroenterology Hepatology and Nutrition, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Alan R Smyth
- Division of Child Health, Obstetrics & Gynaecology (COG), University of Nottingham, Nottingham, UK
| | - Giovanni Taccetti
- Cystic Fibrosis Centre, Department of Paediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Thomas O F Wagner
- Frankfurter Referenzzentrum für Seltene Erkrankungen (FRZSE), Universitätsklinikum Frankfurt am Main, Wolfgang von Goethe-Universität, Frankfurt am Main, Germany
| | - Susan P Wolfe
- Regional Paediatric CF Unit, The Leeds Children's Hospital, Leeds Teaching Hospitals, Belmont Grove, Leeds, UK
| | - Pavel Drevinek
- Department of Medical Microbiology, Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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32
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Gottlieb J, Greer M. Recent advances in extracorporeal life support as a bridge to lung transplantation. Expert Rev Respir Med 2018; 12:217-225. [PMID: 29369703 DOI: 10.1080/17476348.2018.1433035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Invasive mechanical respiratory support in candidate bridging to transplant (BTT) has become common practice in recent years. This usually consists of mechanical ventilation, extracorporeal life support (ECLS) or a combination of both techniques. Areas covered: This review covers epidemiology, technical considerations, indications and outcome of ELCS as BTT. Published literature was identified by searching the MEDLINE bibliographic database (1946-present) and appropriate papers were reviewed. In a retrospective analysis of the period 2010-2016 (n = 92 cases of ECLS bridging, 62% ECLS only) at our institution, bridging success was 73%, with 1-year survival among patients surviving to transplant 78%, surpassing our previously published results between 2005-2009 (bridging success 58%, 1-year survival 58%, p = 0.002 and p = 0.02, respectively). Expert commentary: While ECLS success has influenced lung transplant selection criteria, bridging remains technically and ethically challenging. Candidate selection and organ allocation are crucial to achieving acceptable results.
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Affiliation(s)
- Jens Gottlieb
- a Department of Respiratory Medicine , Hannover Medical School , Hannover , Germany.,b Biomedical Research in End-stage and Obstructive Disease , German Centre for Lung Research , Hannover , Germany
| | - Mark Greer
- a Department of Respiratory Medicine , Hannover Medical School , Hannover , Germany.,b Biomedical Research in End-stage and Obstructive Disease , German Centre for Lung Research , Hannover , Germany
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33
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Yesterday's heroic measure is now standard procedure: Extracorporeal membrane oxygenation as a bridge to lung transplant. J Thorac Cardiovasc Surg 2017; 155:1314-1315. [PMID: 29198789 DOI: 10.1016/j.jtcvs.2017.10.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/25/2017] [Indexed: 01/19/2023]
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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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Loor G, Simpson L, Parulekar A. Bridging to lung transplantation with extracorporeal circulatory support: when or when not? J Thorac Dis 2017; 9:3352-3361. [PMID: 29221320 DOI: 10.21037/jtd.2017.08.117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with end-stage lung disease who are candidates for lung transplantation may acutely decompensate before a donor organ becomes available. In this scenario, extracorporeal life support (ECLS) may be considered as a bridge to transplant or as a bridge to decision. In the current chapter, we review the indications, techniques, and outcomes for bridging to lung transplantation with ECLS.
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Affiliation(s)
- Gabriel Loor
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Leo Simpson
- Department of Cardiopulmonary Transplantation, the Center for Cardiac Support, Texas Heart Institute, Houston, TX, USA
| | - Amit Parulekar
- Section of Pulmonary, Critical Care and Sleep Medicine, CHI St. Luke's Health-Baylor St. Luke's Medical Center, Houston, TX, USA
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Abstract
With more than 50,000 procedures having been performed worldwide, lung transplantation (LT) has become the standard of care for patients with end-stage chronic respiratory failure. LT leads to dramatic improvements in both pulmonary function and health related quality of life. Survival after LTs has steadily improved, but still lags far behind that observed after other solid organ transplantations, as evidenced by a median survival rate that currently stands at 5.8 years. Because of these disappointing results, the ability of LT to expand survival has been questioned. However, the most recent studies, based on sophisticated statistical modeling suggest that LT confers a survival benefit to the vast majority of lung transplant recipients. Chronic lung allograft dysfunction (CLAD) that develops in about 50% of recipients 5 years after LT is a major impediment to lung transplant survival. A better understanding of the mechanisms underlying CLAD could allow for better post-transplant survival.
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Affiliation(s)
- Gabriel Thabut
- Service de pneumologie et transplantation pulmonaire, Hôpital Bichat, Paris, France
| | - Herve Mal
- INSERM U1152, Université Paris Diderot, Paris, France
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37
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Todd EM, Biswas Roy S, Hashimi AS, Serrone R, Panchanathan R, Kang P, Varsch KE, Steinbock BE, Huang J, Omar A, Patel V, Walia R, Smith MA, Bremner RM. Extracorporeal membrane oxygenation as a bridge to lung transplantation: A single-center experience in the present era. J Thorac Cardiovasc Surg 2017; 154:1798-1809. [PMID: 29042051 DOI: 10.1016/j.jtcvs.2017.06.063] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 04/03/2017] [Accepted: 06/27/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation has been used as a bridge to lung transplantation in patients with rapid pulmonary function deterioration. The reported success of this modality and perioperative and functional outcomes are varied. METHODS We retrospectively reviewed all patients who underwent lung transplantation at our institution over 1 year (January 1, 2015, to December 31, 2015). Patients were divided into 2 groups depending on whether they required extracorporeal membrane oxygenation support as a bridge to transplant; preoperative characteristics, lung transplantation outcomes, and survival were compared between groups. RESULTS Of the 93 patients, 12 (13%) received bridge to transplant, and 81 (87%) did not. Patients receiving bridge to transplant were younger, had higher lung allocation scores, had lower functional status, and were more often on mechanical ventilation at listing. Most patients who received bridge to transplant (n = 10, 83.3%) had pulmonary fibrosis. Mean pretransplant extracorporeal membrane oxygenation support was 103.6 hours in duration (range, 16-395 hours). All patients who received bridge to transplant were decannulated immediately after lung transplantation but were more likely to return to the operating room for secondary chest closure or rethoracotomy. Grade 3 primary graft dysfunction within 72 hours was similar between groups. Lung transplantation success and hospital discharge were 100% in the bridge to transplant group; however, these patients experienced longer hospital stays and higher rates of discharge to acute rehabilitation. The 1-year survival was 100% in the bridge to transplant group and 91% in the non-bridge to transplant group (log-rank, P = .24). The 1-year functional status was excellent in both groups. CONCLUSIONS Extracorporeal membrane oxygenation can be used to safely bridge high-acuity patients with end-stage lung disease to lung transplantation with good 30-day, 90-day, and 1-year survival and excellent 1-year functional status. Long-term outcomes are being studied.
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Affiliation(s)
- Emily M Todd
- Perfusion Department, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Sreeja Biswas Roy
- Department of Research Grants, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - A Samad Hashimi
- Division of Thoracic Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Rosemarie Serrone
- Department of Surgery, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Roshan Panchanathan
- University of Arizona College of Medicine, University of Arizona, Phoenix, Ariz
| | - Paul Kang
- University of Arizona College of Public Health, University of Arizona, Phoenix, Ariz
| | - Katherine E Varsch
- Department of Lung Transplantation, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Barry E Steinbock
- Perfusion Department, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Jasmine Huang
- Division of Thoracic Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Ashraf Omar
- Division of Pulmonology, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Vipul Patel
- Division of Pulmonology, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Rajat Walia
- Division of Pulmonology, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Michael A Smith
- Division of Thoracic Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz
| | - Ross M Bremner
- Division of Thoracic Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, Ariz.
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38
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Mulvihill MS, Yerokun BA, Davis RP, Ranney DN, Daneshmand MA, Hartwig MG. Extracorporeal membrane oxygenation following lung transplantation: indications and survival. J Heart Lung Transplant 2017; 37:S1053-2498(17)31880-6. [PMID: 28712677 DOI: 10.1016/j.healun.2017.06.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is employed to rescue patients with early graft dysfunction after lung transplantation (LTx). Rates of post-LTx ECMO and subsequent outcomes have been limited to single-center reports. METHODS UNOS registry was queried for LTx recipients from March 2015 to March 2016; 2,001 recipients were identified and stratified by need for post-LTx ECMO. Logistic regression was used to determine variables associated with post-LTx ECMO. Cox proportional hazards modeling identified factors associated with survival. Kaplan-Meier analysis with log-rank testing was employed for survival analysis. RESULTS Of 2,001 recipients identified, 107 required post-LTx ECMO (5.1%). Recipients requiring ECMO were younger (56 vs 60 years, p = 0.007) and had higher body mass index (27.2 vs 25.8, p = 0.012). Recipients requiring post-LTx ECMO were more likely to have required mechanical ventilation before transplant (9.3% vs 4.9%, p = 0.049) and were more likely to have required pre-transplant ECMO (15% vs 3.7%, p < 0.001). On multivariable analysis, pre-transplant ECMO and increasing ischemic time were associated with post-LTx ECMO. Six-month survival for recipients requiring ECMO was 62.2%. On multivariable analysis, need for post-transplant dialysis was associated with mortality. Six-month survival for recipients requiring ECMO with and without dialysis was 25.8% and 86.7% (p < 0.001). CONCLUSIONS In a nationally representative database, ischemic time and pre-transplant ECMO and/or ventilator requirement were associated with need for post-LTx ECMO. Need for post-transplant dialysis was associated with mortality in patients requiring post-LTx ECMO. These data may permit improved prediction of graft dysfunction. Strategies to minimize renal toxicity in the perioperative phase may lead to improved early survival post-LTx.
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Affiliation(s)
- Michael S Mulvihill
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Babatunde A Yerokun
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Robert Patrick Davis
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - David N Ranney
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mani A Daneshmand
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Banga A, Batchelor E, Mohanka M, Bollineni S, Kaza V, Mullins J, Tran M, Bajona P, Peltz M, Wait M, Torres F. Predictors of outcome among patients on extracorporeal membrane oxygenation as a bridge to lung transplantation. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.12990] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Amit Banga
- Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Elizabeth Batchelor
- Department of Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Manish Mohanka
- Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Srinivas Bollineni
- Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Vaidehi Kaza
- Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Jessica Mullins
- Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Melissa Tran
- Department of Nursing; CVICU; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Pietro Bajona
- Division of Cardiothoracic Surgery; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Matthias Peltz
- Division of Cardiothoracic Surgery; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Michael Wait
- Division of Cardiothoracic Surgery; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Fernando Torres
- Division of Pulmonary & Critical Care Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
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Spontaneously Breathing Extracorporeal Membrane Oxygenation Support Provides the Optimal Bridge to Lung Transplantation. Transplantation 2017; 100:2699-2704. [PMID: 26910331 DOI: 10.1097/tp.0000000000001047] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is being increasingly used as a bridge to lung transplantation. Small, single-institution series have described increased success using ECMO in spontaneously breathing patients compared with patients on ECMO with mechanical ventilation, but this strategy has not been evaluated on a large scale. METHODS Using the United Network for Organ Sharing database, all adult patients undergoing isolated lung transplantation from May 2005 through September 2013 were identified. Patients were categorized by their type of pretransplant support: no support, ECMO only, invasive mechanical ventilation (iMV) only, and ECMO + iMV. Kaplan-Meier survival analysis with log-rank testing was performed to compare survival based on type of preoperative support. A Cox regression model was used to determine whether type of preoperative support was independently associated with survival, using previously established predictors of survival as covariates. RESULTS Approximately 12,403 primary adult pulmonary transplantations were included in this analysis. Sixty-five patients (0.52%) were on ECMO only, 612 (4.93%) required only iMV, 119 (0.96%) were on ECMO + iMV, and the remaining 11,607 (94.6%) required no invasive support before transplantation. One-year survival was decreased in all patients requiring support, regardless of type. However, mid-term survival was similar between patients on ECMO alone and those not on support but significantly worse with patients requiring iMV only or ECMO + iMV. In multivariable analysis, ECMO + iMV and iMV alone were independently associated with decreased survival compared with nonsupport patients, whereas ECMO alone was not significant. CONCLUSIONS In patients with worsening pulmonary disease awaiting lung transplantation, those supported via ECMO with spontaneous breathing demonstrated improved survival compared with other bridging strategies.
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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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Biscotti M, Gannon WD, Agerstrand C, Abrams D, Sonett J, Brodie D, Bacchetta M. Awake Extracorporeal Membrane Oxygenation as Bridge to Lung Transplantation: A 9-Year Experience. Ann Thorac Surg 2017; 104:412-419. [PMID: 28242078 DOI: 10.1016/j.athoracsur.2016.11.056] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/26/2016] [Accepted: 11/17/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used as a bridge to lung transplantation, but characteristics that influence its success are poorly understood. This large, single-center experience evaluated the implementation and outcomes of ECMO in this setting. METHODS Data were collected for patients at our institution (New York-Presbyterian Hospital/Columbia University Medical Center in New York) who received ECMO as a bridge to lung transplantation from January 1, 2007 through July 10, 2016. Data were analyzed for demographics, baseline characteristics, survival, and ECMO configuration. RESULTS Seventy-two patients received ECMO as a bridge to lung transplantation. Of the 72 patients, 40 (55.6%) underwent the transplantation procedure, 37 (92.5%) survived to discharge, and 21 (84.0%) survived for 2 years. Inotropy or vasopressor support (70% vs 93.8%; p = 0.011), Simplified Acute Physiology Score (26.8 vs 30.5; p = 0.048), and ambulation (80% vs 56.2%; p = 0.030) were significantly different between the patients who underwent lung transplantation and those who did not. Patients with cystic fibrosis were more likely to have a bridge to transplantation than patients with other lung diseases (47.5% vs 25%; p = 0.050). Daily participation in physical therapy was achieved in 50 patients (69.4%). CONCLUSIONS This study demonstrated favorable survival in patients receiving ECMO as a bridge to lung transplantation and achieved high rates of physical therapy and avoidance of mechanical ventilation while ECMO was used in patients awaiting lung transplantation. With more than half of these patients successfully bridged to lung transplantation, we gained insight into the factors influencing patients' outcomes, including patient selection, timing of ECMO, and patient management.
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Affiliation(s)
- Mauer Biscotti
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Whitney D Gannon
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Cara Agerstrand
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Darryl Abrams
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Joshua Sonett
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Matthew Bacchetta
- Division of Cardiothoracic Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.
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Rajagopal K, Hoeper MM. State of the Art: Bridging to lung transplantation using artificial organ support technologies. J Heart Lung Transplant 2016; 35:1385-1398. [PMID: 27916175 DOI: 10.1016/j.healun.2016.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 10/05/2016] [Accepted: 10/12/2016] [Indexed: 11/29/2022] Open
Abstract
Lung transplantation increasingly is being performed in recipients of higher risk and acuity. A subset of these patients has severely abnormal gas exchange and/or right ventricular dysfunction, such that artificial organ support strategies are required to bridge patients to lung transplantation. We review the rationales and currently used and potential strategies for bridging to lung transplantation and characterize bridging outcomes. Based on physiologic reasoning and a study of the existing literature, we provide a working strategy for bridging to lung transplantation.
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Affiliation(s)
- Keshava Rajagopal
- Center for Advanced Heart Failure and Department of Cardiothoracic/Vascular Surgery, University of Texas-Houston and Memorial Hermann-Texas Medical Center, Houston, Texas.
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, and German Center for Lung Research (DZL), Hannover, Germany
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Chaparro C, Keshavjee S. Lung transplantation for cystic fibrosis: an update. Expert Rev Respir Med 2016; 10:1269-1280. [DOI: 10.1080/17476348.2016.1261016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Principi e indicazioni dell’assistenza circolatoria e respiratoria extracorporea in chirurgia toracica. EMC - TECNICHE CHIRURGICHE TORACE 2016. [PMCID: PMC7159017 DOI: 10.1016/s1288-3336(16)79382-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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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How to minimise ventilator-induced lung injury in transplanted lungs: The role of protective ventilation and other strategies. Eur J Anaesthesiol 2016; 32:828-36. [PMID: 26148171 DOI: 10.1097/eja.0000000000000291] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Lung transplantation is the treatment of choice for end-stage pulmonary diseases. In order to avoid or reduce pulmonary and systemic complications, mechanical ventilator settings have an important role in each stage of lung transplantation. In this respect, the use of mechanical ventilation with a tidal volume of 6 to 8 ml kg(-1) predicted body weight, positive end-expiratory pressure of 6 to 8 cmH2O and a plateau pressure lower than 30 cmH2O has been suggested for the donor during surgery, and for the recipient both during and after surgery. For the present review, we systematically searched the PubMed database for articles published from 2000 to 2014 using the following keywords: lung transplantation, protective mechanical ventilation, lung donor, extracorporeal membrane oxygenation, recruitment manoeuvres, extracorporeal CO2 removal and noninvasive ventilation.
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Fuehner T, Kuehn C, Welte T, Gottlieb J. ICU Care Before and After Lung Transplantation. Chest 2016; 150:442-50. [DOI: 10.1016/j.chest.2016.02.656] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 02/09/2016] [Accepted: 02/22/2016] [Indexed: 12/27/2022] Open
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Reeb J, Olland A, Renaud S, Lejay A, Santelmo N, Massard G, Falcoz PE. Vascular access for extracorporeal life support: tips and tricks. J Thorac Dis 2016; 8:S353-63. [PMID: 27195133 DOI: 10.21037/jtd.2016.04.42] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In thoracic surgery, extracorporeal life support (ECLS) techniques are performed to (I) provide a short to mid term extracorporeal mechanical support; (II) realize the gas exchanges; and (III)-depending the configuration of the circuit-substitute the failed heart function. The objective of this review is to describe the rational of the different ECLS techniques used in thoracic surgery and lung transplantation (LTx) with a specific attention to the vascular access. Venovenous extracorporeal membrane oxygenation (VV ECMO) is the most common ECLS technique used in thoracic surgery and represents the best strategy to support the lung function. VV ECMO needs peripheral vascular access. The selection between his double-site or single-site configuration should be decided according the level of O2 requirements, the nosological context, and the interest to perform an ECLS ambulatory strategy. Venoarterial (VA) ECMO uses peripheral and/or central cannulation sites. Central VA ECMO is mainly used in LTx instead a conventional cardiopulmonary bypass (CPB) to decrease the risk of hemorrhagic issues and the rate of primary graft dysfunction (PGD). Peripheral VA ECMO is traditionally realized in a femoro-femoral configuration. Femoro-femoral VA ECMO allows a cardiocirculatory support but does not provide an appropriate oxygenation of the brain and the heart. The isolated hypercapnic failure is currently supported by extracorporeal CO2 removal (ECCO2R) devices inserted in jugular or subclavian veins. The interest of the Novalung (Novalung GmbH, Hechingen, Germany) persists due to his central configuration indicated to bridge to LTx patients suffering from pulmonary hypertension. The increasing panel of ECLS technologies available in thoracic surgery is the results of a century of clinical practices, engineering progress, and improvements of physiological knowledges. The selection of the ECLS technique-and therefore the vascular access to implant the device-for a given nosological context trends to be defined according an evidence-based medicine.
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Affiliation(s)
- Jeremie Reeb
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Anne Olland
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Stephane Renaud
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Anne Lejay
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Nicola Santelmo
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Gilbert Massard
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
| | - Pierre-Emmanuel Falcoz
- 1 Division of Thoracic Surgery and Strasbourg Lung Transplant Program, 2 Division of Vascular Surgery and Kidney Transplantation, Strasbourg University Hospital, 1 place de l'Hôpital, 67091 Strasbourg Cedex, France
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Girgis RE, Khaghani A. A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure. Glob Cardiol Sci Pract 2016; 2016:e201605. [PMID: 29043255 PMCID: PMC5642749 DOI: 10.21542/gcsp.2016.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 04/08/2016] [Indexed: 11/17/2022] Open
Abstract
Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.
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Affiliation(s)
- Reda E. Girgis
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health,
| | - Asghar Khaghani
- Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
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Hayanga JWA, Aboagye JK, Hayanga HK, Luketich JD, D'Cunha J. Extracorporeal membrane oxygenation as a bridge to lung re-transplantation: Is there a role? J Heart Lung Transplant 2016; 35:901-5. [PMID: 27435530 DOI: 10.1016/j.healun.2016.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND In this study we sought to determine survival rates after use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung re-transplantation (re-LT). METHODS Propensity-adjusted analysis was performed on data from the Scientific Registry of Transplant Recipients (SRTR) to evaluate survival in recipients between the years 1988 and 2012, based on the use of ECMO before re-LT. RESULTS A total of 854 adult re-LT recipients were identified. Extracorporeal support had been used as a bridge in 55 (6.8%) of the recipients, whereas 799 (93.2%) had undergone re-LT without the use of ECMO. Compared with non-ECMO patients, the ECMO patients were more likely to have: higher body mass index (p = 0.003); received lungs from an older donor (p = 0.04); higher total bilirubin (p = 0.002); undergone bilateral lung transplantation (p = 0.01); diabetes (p = 0.04); mechanical ventilation (p < 0.0005); and been hospitalized in the intensive care unit (p < 0.0001). They were also more likely to have a diagnosis of bronchiolitis obliterans syndrome (p < 0.0001), be on inhaled nitric oxide (p < 0.0001), and have a shorter waitlist time before re-LT (p < 0.0001). Compared with the non-ECMO group, 30-day survival for the ECMO group was lower (67.3% vs 91.2%, p = 0.0002). Obesity was identified as a predictor of increased mortality in re-LT hazard ratio 2.97 (1.18 to 7.50), p = 0.02. CONCLUSION This contemporary analysis of survival after use of ECMO as a bridge to re-LT revealed lower survival in the ECMO group.
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Affiliation(s)
- J W Awori Hayanga
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Jonathan K Aboagye
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heather K Hayanga
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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