1
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Ndubisi N, van Berkel V. Veno-venous extracorporeal membrane oxygenation for the treatment of respiratory compromise. Indian J Thorac Cardiovasc Surg 2023; 39:1-7. [PMID: 36778720 PMCID: PMC9905006 DOI: 10.1007/s12055-022-01467-3] [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: 10/06/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 02/11/2023] Open
Abstract
Extracorporeal membrane oxygenation for the purpose of intervening upon profound cardiovascular or pulmonary compromise has proven to be a worthy intervention. Technological advancements have allowed this mode of therapy to become more effective and widespread. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a commonly used strategy to help manage patients with pulmonary dysfunction refractory to traditional management methods. This review intends to focus upon common indications and the clinical considerations for the institution of VV-ECMO as well as some of its known complications.
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Affiliation(s)
- Nnaemeka Ndubisi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, 201 Abraham Flexnor Way, Suite 1200, Louisville, KY 40202 USA
| | - Victor van Berkel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, 201 Abraham Flexnor Way, Suite 1200, Louisville, KY 40202 USA
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2
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Hartwig M, van Berkel V, Bharat A, Cypel M, Date H, Erasmus M, Hoetzenecker K, Klepetko W, Kon Z, Kukreja J, Machuca T, McCurry K, Mercier O, Opitz I, Puri V, Van Raemdonck D. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation. J Thorac Cardiovasc Surg 2023; 165:301-326. [PMID: 36517135 DOI: 10.1016/j.jtcvs.2022.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation. METHODS The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement. RESULTS The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively. CONCLUSIONS Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.
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Affiliation(s)
- Matthew Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Durham, NC.
| | | | | | | | - Hiroshi Date
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Michiel Erasmus
- University Academic Center Groningen, Groningen, The Netherlands
| | | | | | | | - Jasleen Kukreja
- University of California San Francisco, San Francisco, Calif
| | - Tiago Machuca
- University of Florida College of Medicine, Gainesville, Fla
| | | | - Olaf Mercier
- Université Paris-Saclay and Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | | | - Varun Puri
- Washington University School of Medicine, St Louis, Mo
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3
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Faccioli E, Terzi S, Pangoni A, Lomangino I, Rossi S, Lloret A, Cannone G, Marino C, Catelli C, Dell'Amore A. Extracorporeal membrane oxygenation in lung transplantation: Indications, techniques and results. World J Transplant 2021; 11:290-302. [PMID: 34316453 PMCID: PMC8290996 DOI: 10.5500/wjt.v11.i7.290] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/13/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in the field of lung transplantation has rapidly expanded over the past 30 years. It has become an important tool in an increasing number of specialized centers as a bridge to transplantation and in the intra-operative and/or post-operative setting. ECMO is an extremely versatile tool in the field of lung transplantation as it can be used and adapted in different configurations with several potential cannulation sites according to the specific need of the recipient. For example, patients who need to be bridged to lung transplantation often have hypercapnic respiratory failure that may preferably benefit from veno-venous (VV) ECMO or peripheral veno-arterial (VA) ECMO in the case of hemodynamic instability. Moreover, in an intra-operative setting, VV ECMO can be maintained or switched to a VA ECMO. The routine use of intra-operative ECMO and its eventual prolongation in the post-operative period has been widely investigated in recent years by several important lung transplantation centers in order to assess the graft function and its potential protective role on primary graft dysfunction and on ischemia-reperfusion injury. This review will assess the current evidence on the role of ECMO in the different phases of lung transplantation, while analyzing different studies on pre, intra- and post-operative utilization of this extracorporeal support.
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Affiliation(s)
- Eleonora Faccioli
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Stefano Terzi
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Alessandro Pangoni
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Ivan Lomangino
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Sara Rossi
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Andrea Lloret
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Giorgio Cannone
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Carlotta Marino
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Chiara Catelli
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
| | - Andrea Dell'Amore
- Thoracic Surgery Unit, Department of Cardiothoracic and Vascular Sciences, University of Padova, Padova 35128, Italy
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4
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Martin AK, Jayaraman AL, Nabzdyk CG, Wilkey BJ, Fritz AV, Kolarczyk L, Ramakrishna H. Extracorporeal Membrane Oxygenation in Lung Transplantation: Analysis of Techniques and Outcomes. J Cardiothorac Vasc Anesth 2020; 35:644-661. [PMID: 32546408 DOI: 10.1053/j.jvca.2020.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/10/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Arun L Jayaraman
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Scottsdale, AZ
| | - Christoph G Nabzdyk
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Barbara J Wilkey
- Department of Anesthesiology, University of Colorado Denver, Aurora, CO
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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5
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Dell'Amore A, Campisi A, Congiu S, Mazzarra S, Pastore S, Dolci G, Baiocchi M, Frascaroli G. Extracorporeal life support during and after bilateral sequential lung transplantation in patients with pulmonary artery hypertension. Artif Organs 2020; 44:628-637. [PMID: 31885090 DOI: 10.1111/aor.13628] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/12/2019] [Accepted: 12/27/2019] [Indexed: 12/12/2022]
Abstract
The use of extracorporeal membrane oxygenator instead of standard cardiopulmonary bypass during lung transplantation is debatable. Moreover, recently, the concept of prolonged postoperative extracorporeal membrane oxygenator (ECMO) support has been introduced in many transplant centers to prevent primary graft dysfunction (PGD) and improve early and long-term results. The objective of this study was to review the results of our extracorporeal life support strategy during and after bilateral sequential lung transplantation (BSLT) for pulmonary artery hypertension. We review retrospectively our experience in BSLT for pulmonary artery hypertension between January 2010 and August 2018. A total of 38 patients were identified. Nine patients were transplanted using cardiopulmonary bypass (CPB), in eight cases CPB was followed by a prolonged ECMO (pECMO) support, 14 patients were transplanted on central ECMO support, and seven patients were transplanted with central ECMO support followed by a pECMO assistance. The effects of different support strategies were evaluated, in particular in-hospital morbidity, mortality, incidence of PGD, and long-term follow-up. The use of CPB was associated with poor postoperative results and worse long-term survival compared with ECMO-supported patients. Predictive preoperative factors for the need of intraoperative CPB instead of ECMO were identified. The pECMO strategy had a favorable effect to mitigate postoperative morbidity and mortality, not only in intraoperative ECMO-supported patients, but even in CPB-supported cases. In our experience, ECMO may be considered as the first choice circulatory support for lung transplantation. Sometimes, in very complex cases, CBP is still necessary. The pECMO strategy is very effective to reduce incidence of PGD even in CPB-supported patients.
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Affiliation(s)
- Andrea Dell'Amore
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Alessio Campisi
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Stefano Congiu
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Sara Mazzarra
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Saverio Pastore
- Cardio-Thoracic Anesthesiology Unit, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Giampiero Dolci
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Massimo Baiocchi
- Cardio-Thoracic Anesthesiology Unit, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Guido Frascaroli
- Cardio-Thoracic Anesthesiology Unit, S.Orsola Malpighi University Hospital, Bologna, Italy
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6
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Ius F, Tudorache I, Warnecke G. Extracorporeal support, during and after lung transplantation: the history of an idea. J Thorac Dis 2018; 10:5131-5148. [PMID: 30233890 DOI: 10.21037/jtd.2018.07.43] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
During recent years, continuous technological innovation has provoked an increase of extracorporeal life support (ECLS) use for perioperative cardiopulmonary support in lung transplantation. Initial results were disappointing, due to ECLS-specific complications and high surgical risk of the supported patients. However, the combination of improved patient management, multidisciplinary team work and standardization of ECLS protocols has recently yielded excellent results in several case series from high-volume transplant centres. Therein, it was demonstrated that, although the prevalence of complications remains higher in supported patients, there may be no difference in long-term graft function between supported and non-supported patients. These results are important, because most of the patients who require ECLS support in lung transplantation are young and have no other chance to survive, but to be transplanted. Moreover, there is no device for "bridging to destination" therapy in lung transplantation. Of note, the evidence in favour of ECLS support in lung transplantation was never validated by randomized controlled trials, but by everyday experience at the patient bed-side. Here, we review the state-of-the-art ECLS evidence for intraoperative and postoperative cardiopulmonary support in lung transplantation.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Center for Lung Research (DZL/BREATH), Hannover, Germany
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7
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Song JH, Park JE, Lee JG, Lee CY, Nam KS, Suh JW, Kim A, Lee SH, Joo HC, Youn YN, Kim SY, Park MS, Paik HC. Outcomes of perioperative extracorporeal membrane oxygenation use in patients undergoing lung transplantation. J Thorac Dis 2017; 9:5075-5084. [PMID: 29312713 DOI: 10.21037/jtd.2017.10.142] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background The aim of this single-center study is to review the transplant outcomes of patients receiving lung transplantation (LTx) using intraoperative extracorporeal membrane oxygenation (ECMO) according to the perioperative use of ECMO. Methods We retrospectively reviewed the transplant outcomes of 107 consecutive patients who underwent LTx using intraoperative ECMO between March 2013 and August 2016 at Severance Hospital of Yonsei University (Seoul, Korea). Results Patients were divided into the following three groups according to the use of perioperative ECMO: only intraoperative ECMO (n=47) or extended post-operative ECMO but no bridging and no postoperative ECMO re-implantation (secondary ECMO; n=28) as Group A (n=75); bridging ECMO without secondary ECMO (n=14) as Group B; and secondary ECMO with (n=7) or without (n=11) bridging as Group C. Baseline demographics were comparable among the three groups. The mean duration of preoperative ECMO bridging was 16.4±15.6 (n=21). After a median of 17.7 months (range, 3.1-40.9 months) for survivors, the one year overall survival (OS) rates after LTx for the three groups were 76.3%±5.2% for Group A, 59.9%±14.3% for Group B, and 14.0%±9.0% for Group C (P<0.0001). The secondary ECMO (Group C) was established a mean of 7.9±5.3 days after LTx. The main cause of secondary ECMO was acute respiratory failure from pneumonia, and the main cause of death was infection-related events. Conclusions Our data suggests that the use of perioperative ECMO, including its extended postoperative use during LTx, is feasible and has favorable outcomes. However, as shown by the poor survival outcome after secondary ECMO, the development of solid strategy to reduce the need for secondary ECMO implantation after LTx seems important.
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Affiliation(s)
- Joo Han Song
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Eun Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Young Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Nam
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Won Suh
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Anes Kim
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Chel Joo
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Nam Youn
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Song Yee Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Moo Suk Park
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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8
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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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9
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Increased Extravascular Lung Water and Plasma Biomarkers of Acute Lung Injury Precede Oxygenation Impairment in Primary Graft Dysfunction After Lung Transplantation. Transplantation 2017; 101:112-121. [PMID: 27495752 DOI: 10.1097/tp.0000000000001434] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND After lung transplantation (LT), early prediction of grade 3 pulmonary graft dysfunction (PGD) remains a research gap for clinicians. We hypothesized that it could be improved using extravascular lung water (EVLWi) and plasma biomarkers of acute lung injury. METHODS After institutional review board approval and informed consent, consecutive LT recipients were included. Transpulmonary thermodilution-based EVLWi, plasma concentrations of epithelial (soluble receptor for advanced glycation endproducts [sRAGE]) and endothelial biomarkers (soluble intercellular adhesion molecule-1 and endocan [full-length and cleaved p14 fragment]) were obtained before and after LT (0 [H0], 6, 12, 24, 48 and 72 hours after pulmonary artery unclamping). Grade 3 PGD was defined according to the International Society for Lung and Heart Transplantation definition, combining arterial oxygen partial pressure (PaO2)/inspired fraction of oxygen (FiO2) ratio and chest X-rays. Association of clinical risk factors, EVLWi and biomarkers with grade 3 PGD was analyzed under the Bayesian paradigm, using logistic model and areas under the receiver operating characteristic curves (AUCs). RESULTS In 47 LT recipients, 10 developed grade 3 PGD, which was obvious at H6 in 8 cases. Clinical risk factors, soluble intercellular adhesion molecule-1 and endocan (both forms) were not associated with grade 3 PGD. Significant predictors of grade 3 PGD included (1) EVLWi (optimal cutoff, 13.7 mL/kg; AUC, 0.74; 95% confidence interval [CI], 0.48-0.99), (2) PaO2/FiO2 ratio (optimal cutoff, 236; AUC, 0.68; 95% CI, 0.52-0.84), and (3) sRAGE (optimal cutoff, 11 760 pg/mL; AUC, 0.66; 95% CI, 0.41-0.91) measured at H0. CONCLUSIONS Immediate postreperfusion increases in EVLWi and sRAGE along with impaired PaO2/FiO2 ratios were early predictors of grade 3 PGD at or beyond 6 hours and may trigger early therapeutic interventions.
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10
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San Roman E, Venuti MS, Ciarrocchi NM, Fernández Ceballos I, Gogniat E, Villarroel S, Carini FC, Giannasi SE. Implementation and results of a new ECMO program for lung transplantation and acute respiratory distress. Rev Bras Ter Intensiva 2016; 27:134-40. [PMID: 26340153 PMCID: PMC4489781 DOI: 10.5935/0103-507x.20150024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 04/03/2015] [Indexed: 01/19/2023] Open
Abstract
Objective The development of the extracorporeal membrane oxygenation in Latin America
represents a challenge in this specialty field. The objective of this article was
to describe the results of a new extracorporeal membrane oxygenation program in an
intensive care unit. Methods This retrospective cohort study included 22 patients who required extracorporeal
membrane oxygenation and were treated from January 2011 to June 2014. The baseline
characteristics, indications, duration of the condition, days on mechanical
ventilation, days in the intensive care unit, complications, and hospital
mortality were evaluated. Results Fifteen patients required extracorporeal membrane oxygenation after lung
transplantation, and seven patients required oxygenation due to acute respiratory
distress. All transplanted patients were weaned from extracorporeal membrane
oxygenation with a median duration of 3 days (Interquartile range - IQR: 2 - 5),
were on mechanical ventilation for a median of 15.5 days (IQR: 3 - 25), and had an
intensive care unit stay of 31.5 days (IQR: 19 - 53) and a median hospital stay of
60 days (IQR: 36 - 89) with 20% mortality. Patients with acute respiratory
distress had a median oxygenation membrane duration of 9 days (IQR: 3 - 14),
median mechanical ventilation time of 25 days (IQR: 13 - 37), a 31 day stay in
therapy (IQR: 11 - 38), a 32 day stay in the hospital (IQR: 11 - 41), and 57%
mortality. The main complications were infections (80%), acute kidney failure
(43%), bleeding at the surgical site and at the site of cannula placement (22%),
plateletopenia (60%), and coagulopathy (30%). Conclusion In spite of the steep learning curve, we considered this experience to be
satisfactory, with results and complications comparable to those reported in the
literature.
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Affiliation(s)
- Eduardo San Roman
- Unidad de Terapia Intensiva de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - María Sofía Venuti
- Unidad de Terapia Intensiva de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Emiliano Gogniat
- Unidad de Terapia Intensiva de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sonia Villarroel
- Unidad de Terapia Intensiva de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Federico Carlos Carini
- Unidad de Terapia Intensiva de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sergio Eduardo Giannasi
- Unidad de Terapia Intensiva de Adultos, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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11
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Ius F, Sommer W, Tudorache I, Avsar M, Siemeni T, Salman J, Molitoris U, Gras C, Juettner B, Puntigam J, Optenhoefel J, Greer M, Schwerk N, Gottlieb J, Welte T, Hoeper MM, Haverich A, Kuehn C, Warnecke G. Five-year experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: Indications and midterm results. J Heart Lung Transplant 2015; 35:49-58. [PMID: 26496786 DOI: 10.1016/j.healun.2015.08.016] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/18/2015] [Accepted: 08/27/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Since April 2010, extracorporeal membrane oxygenation (ECMO) has replaced cardiopulmonary bypass for intraoperative support during lung transplantation at our institution. The aim of this study was to present our 5-year experience with this technique. METHODS Records of patients who underwent transplantation between April 2010 and January 2015 were retrospectively reviewed. Patients who underwent transplantation without ECMO formed Group A. Patients in whom the indication for ECMO support was set a priori before the beginning of the operation formed Group B. The remaining patients in whom the indication for ECMO support was set during transplantation formed Group C. RESULTS Among 595 patients, 425 (71%) patients (Group A) did not require intraoperative ECMO; the remaining 170 (29%) patients did. Among these patients, 95 (56%) patients formed Group B, and the remaining 75 (44%) patients comprised Group C. Pulmonary fibrosis and pre-operative dilated or hypertrophied right ventricle emerged as risk factors for the indication of non-a priori intraoperative ECMO. Patients in Groups B and C showed a higher pre-operative risk profile and higher prevalence of post-operative complications than patients in Group A. Overall survival at 1 year was 93%, 83%, and 82% and at 4 years was 73%, 68%, and 69% in Groups A, B, and C (p = 0.11). The intraoperative use of ECMO did not emerge as a risk factor for in-hospital mortality or mortality after hospital discharge. CONCLUSIONS Intraoperative ECMO filled the gap between pre-operative and post-operative ECMO in lung transplantation. Although complications and in-hospital mortality were higher in patients who received ECMO, survival was similar among patients who underwent transplantation with or without ECMO.
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Affiliation(s)
- Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany; Biomedical Research in End-Stage and Obstructive Lung Disease Hanover (BREATH), Member of the German Center for Lung Research (DZL), Hanover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Ulrich Molitoris
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | | | | | - Jakob Puntigam
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Joerg Optenhoefel
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | | | - Nicolaus Schwerk
- Department of Paediatrics, Hanover Medical School, Hanover, Germany
| | - Jens Gottlieb
- Biomedical Research in End-Stage and Obstructive Lung Disease Hanover (BREATH), Member of the German Center for Lung Research (DZL), Hanover, Germany; Department of Respiratory Medicine
| | - Tobias Welte
- Biomedical Research in End-Stage and Obstructive Lung Disease Hanover (BREATH), Member of the German Center for Lung Research (DZL), Hanover, Germany; Department of Respiratory Medicine
| | - Marius M Hoeper
- Biomedical Research in End-Stage and Obstructive Lung Disease Hanover (BREATH), Member of the German Center for Lung Research (DZL), Hanover, Germany; Department of Respiratory Medicine
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany; Biomedical Research in End-Stage and Obstructive Lung Disease Hanover (BREATH), Member of the German Center for Lung Research (DZL), Hanover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Hanover, Germany; Biomedical Research in End-Stage and Obstructive Lung Disease Hanover (BREATH), Member of the German Center for Lung Research (DZL), Hanover, Germany.
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12
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Gulack BC, Hirji SA, Hartwig MG. Bridge to lung transplantation and rescue post-transplant: the expanding role of extracorporeal membrane oxygenation. J Thorac Dis 2014; 6:1070-9. [PMID: 25132974 DOI: 10.3978/j.issn.2072-1439.2014.06.04] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 05/09/2014] [Indexed: 12/23/2022]
Abstract
Over the last several decades, the growth of lung transplantation has been hindered by a much higher demand for donor lungs than can be supplied, leading to considerable waiting time and mortality among patients waiting for transplant. This has led to the search for an alternative bridging strategy in patients with end-stage lung disease. The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation as well as a rescue strategy post-transplant for primary graft dysfunction (PGD) has been studied previously, however due to initially poor outcomes, its use was not heavily instituted. In recent years, with significant improvement in technologies, several single and multi-center studies have shown promising outcomes related to the use of ECMO as a bridging strategy as well as a therapy for patients suffering from PGD post-transplant. These results have challenged our current notion on ECMO use and hence forced us to reexamine the utility, efficacy and safety of ECMO in conjunction with lung transplantation. Through this review, we will address the various aspects related to ECMO use as a bridge to lung transplantation as well as a rescue post-transplant in the treatment of PGD. We will emphasize newer technologies related to ECMO use, examine recent observational studies and randomized trials of ECMO use before and after lung transplantation, and reflect upon our own institutional experience with the use of ECMO in these difficult clinical situations.
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Affiliation(s)
- Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sameer A Hirji
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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13
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Farooki AM, Bazick-Cuschieri H, Gordon EK, Lee JC, Cantu EC, Augoustides JG. CASE 7--2014 Rescue therapy with early extracorporeal membrane oxygenation for primary graft dysfunction after bilateral lung transplantation. J Cardiothorac Vasc Anesth 2014; 28:1126-32. [PMID: 23999325 PMCID: PMC3969394 DOI: 10.1053/j.jvca.2013.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Indexed: 01/24/2023]
Affiliation(s)
- Ali M Farooki
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
| | | | - Emily K Gordon
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
| | | | - Edward C Cantu
- Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.AMF was a cardiac anesthesia fellow
| | - John G Augoustides
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
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14
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Bittner HB, Lehmann S, Rastan A, Garbade J, Binner C, Mohr FW, Barten MJ. Outcome of extracorporeal membrane oxygenation as a bridge to lung transplantation and graft recovery. Ann Thorac Surg 2012; 94:942-9; author reply 949-50. [PMID: 22748640 DOI: 10.1016/j.athoracsur.2012.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 04/27/2012] [Accepted: 05/02/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Indications for extracorporeal membrane oxygenation (ECMO) use in lung transplantation are (1) temporary assistance as a bridge to transplantation, (2) stabilization of hemodynamics during transplantation in place of cardiopulmonary bypass, and (3) treatment of severe lung dysfunction and primary graft failure after transplantation. This study compares the survival of lung transplant recipients requiring ECMO support with survival of patients without ECMO. METHODS A retrospective database review was performed for 108 consecutive patients who underwent single-lung or bilateral-lung transplantation at our center between 2002 and 2009. RESULTS Of 108 transplant recipients, 27 (25%) required venoarterial ECMO compared with 81 patients who did not. Nine patients required ECMO preoperatively (87±102 hours), and ECMO was continued for 5 patients during the lung transplant operation. Seven additional patients received ECMO during transplantation. Six patients required early (<7 days) and 5 patients delayed (≥7 days) postoperative ECMO for treatment of allograft dysfunction. The subgroup with support showed the most favorable patient discharge rate (66.7%). ECMO support was a significant risk factor for death (p<0.001). Survival was significantly reduced with the use of ECMO: 30-day, 90-day, 1-year, and 5-year survival was 97%, 91%, 83%, and 58% in the patients without ECMO compared with 63%, 44%, 33%, and 21% in those with ECMO, respectively. CONCLUSIONS Survival after lung transplantation was significantly reduced with ECMO. However, patients who survived the first year showed similar long-term survival as those patients who did not need perioperative ECMO support.
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15
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Lee JC, Diamond JM, Christie JD. Critical care management of the lung transplant recipient. CURRENT RESPIRATORY CARE REPORTS 2012; 1:168-176. [PMID: 32288970 PMCID: PMC7102351 DOI: 10.1007/s13665-012-0018-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Lung transplantation provides the prospect of improved survival and quality of life for patients with end stage lung and pulmonary vascular diseases. Given the severity of illness of such patients at the time of surgery, lung transplant recipients require particular attention in the immediate post-operative period to ensure optimal short-term and long-term outcomes. The management of such patients involves active involvement of a multidisciplinary team versed in common post-operative complications. This review provides an overview of such complications as they pertain to the practitioners caring for post-operative lung transplant recipients. Causes and treatment of conditions affecting early morbidity and mortality in lung transplant recipients will be detailed, including primary graft dysfunction, cardiovascular and surgical complications, and immunologic and infectious issues. Additionally, lung donor management issues and bridging the critically ill potential lung transplant recipient to transplantation will be discussed.
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Affiliation(s)
- James C. Lee
- Penn Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 826 West Gates Pavilion, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Joshua M. Diamond
- Penn Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 826 West Gates Pavilion, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Jason D. Christie
- Department of Biostatistics and Epidemiology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
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