Extracorporeal membrane oxygenation post lung transplantation

Abstract

Extracorporeal membrane oxygenation (ECMO) has been employed as a management strategy to support the failing pulmonary allograft following lung transplantation. We review the indications, technical considerations, management strategies, and outcomes of using ECMO after lung transplantation. ECMO is typically indicated for early pulmonary allograft failure despite optimized conventional support measures. Initiation of ECMO has been advocated early in the postoperative course (<48 h) when ventilatory requirements reach a peak inspiratory pressure of 35 cmH2O or FiO2 surpasses 60% in order to reduce oxidative stress and barotrauma from aggressive mechanical ventilation. Both veno-venous approach and dual-stage cannulation have the potential to reduce thromboembolic complications and enable patient mobilization. Key management strategies while on ECMO include minimizing sedation, pressure-controlled ventilator support minimizing FiO2, and maintaining a hypovolemic state as tolerated. Bivalruden has been proposed as an anticoagulation alternative to heparin, which may ameliorate the effects of heparin resistance or heparin-induced thrombocytopenia syndrome. Single-center series have documented successful ECMO wean in as high as 96% of patients with 30-day survival of 82% and a 1-year survival of 64%. Advances in technology and management strategies continue to increase the effectiveness of ECMO in supporting the failing pulmonary allograft.