Paving a pathway for successful implementation of extracorporeal membrane oxygenation as a bridge to lung transplantation.

Association between Pre-Transplant Allosensitization by ECMO Bridging and Adverse Postoperative Outcome of Lung Transplantation

Primary graft dysfunction after heart transplant is associated with high morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) can be used to wean patients from cardiopulmonary bypass. This study retrospectively reviews a single-centre experience of post-transplant ECMO in regard to outcomes and associated costs. Between May 2006 and May 2019, a total of 267 adult heart transplants were performed. We compared donor and recipient variables, ECMO duration and the incidence of renal failure, bleeding, infection and cost analysis between ECMO and non-ECMO groups. ECMO support was required postoperatively to manage primary graft dysfunction in 72 (27%) patients. The mean duration of ECMO support was 6 ± 3.2 days. Mean ischaemic times were similar between the groups. There was a significantly higher proportion of ventricular assist device explant to transplant in the ECMO group versus non-ECMO (38.2% vs 14.1%; P < 0.0001). ECMO patients had a longer duration of stay in the intensive care unit (P < 0.0001) and total hospital stay (P < 0.0001). Greater mortality was observed in the ECMO group (P < 0.0001). The median cost of providing ECMO was £18000 [interquartile range (IQR): £12750-£24000] per patient with an additional median £35225 (IQR: £21487.25-£51780.75) for ITU stay whilst on ECMO. The total median cost per patient inclusive of hospital stay, ECMO and dialysis costs was £65737.50 (IQR: £52566.50-£95221.75) in the non-ECMO group compared to £145415.71 (IQR: £102523.21-£200618.96) per patient in the ECMO group (P < 0.0001). Patients with primary graft dysfunction following heart transplantation who require ECMO are frequently bridged to a recovery; however, the medium and longer-term survival for these patients is poorer than for patients who do not require ECMO.

Early Gait Function After Lung Transplantation in Patients With and Without Pretransplant Extracorporeal Membrane Oxygenation Support

BackgroundIntraoperative Extracorporeal membrane oxygenation (ECMO) is increasingly being applied as life-support for lung transplantation patients. However, factors associated with this procedure in lung transplantation patients have not yet been characterized. The aim of this study was to identify preoperative factors of intraoperative ECMO support during lung transplantation and to evaluated the outcome of lung transplantation patients supported with ECMO.MethodsPatients underwent lung transplantation treated with and without ECMO in Guangzhou Institute of Respiratory Diseases between January 2015 to August 2018 were retrospectively reviewed. Patient demographics and clinical variables were collected and analyzed. Multivariate logistic regression was performed to identify factors independently associated with intraoperative extracorporeal membrane oxygenation support during lung transplantation.ResultsDuring the study period, 138 patients underwent lung transplantation at our institution, the mean LAS was (56.63 ± 18.39) (range, 32.79 to 88.70). Fourty four patients were treated with veno-venous/veno-arterial ECMO. Among the patients, 32 patients wean successfully ECMO after operation, 12 patients remain ECMO after operation, and 32 patients (62.74%) survived to hospital discharge. In multiple analysis, the following factors were associated with intraoperative ECMO support: advanced age, high PAP before operation, duration of mechanical ventilation before operation, a higher APACHE II and primary diagnosis for transplantation. The overall survival rates at 1, 3, and 12 months were 90.91, 72.73, and 56.81% in the ECMO group, and 95.40, 82.76, and 73.56% in the non-ECMO group, respectively (log-rank P = 0.081). Patients who underwent single lung transplant had a lower survival rates in ECMO group as compared with non-ECMO group at 1, 3, and 12 months (90.47% vs 98.25, 71.43% vs 84.21, and 52.38% vs 75.44%) (log-rank P = 0.048).ConclusionsThe preoperative factors of intraoperative ECMO support during lung transplantation included age, high PAP before operation, preoperative mechanical ventilation, a higher APACHE II and primary diagnosis for transplantation based on multivariate analysis.

We aimed to evaluate the outcomes of post-traumatic acute respiratory distress syndrome (ARDS) in young patients with and without Extracorporeal membrane oxygenation (ECMO) support. A retrospective analysis was conducted for trauma patients who developed ARDS at a level I trauma facility between 2014 and 2020. Data were analyzed and compared between ECMO and non-ECMO group. We identified 85 patients with ARDS (22 patients had ECMO support and 63 matched patients managed by the conventional mechanical ventilation; 1:3 matching ratio). The two groups were comparable for age, sex, injury severity score, abbreviated injury score, shock index, SOFA score, and head injury. Kaplan Meier survival analysis showed that the survival in the ECMO group was initially close to that of the non-ECMO, however, during follow-up, the survival rate was better in the ECMO group, but did not reach statistical significance (Log-rank, p = 0.43 and Tarone-Ware, p = 0.37). Multivariable logistic regression analysis showed that acute kidney injury (AKI) (Odds ratio 13.03; 95% CI 3.17–53.54) and brain edema (Odds ratio 4.80; 95% CI 1.10–21.03) were independent predictors of mortality. Sub-analysis showed that in patients with severe Murray Lung Injury (MLI) scores, non-ECMO group had higher mortality than the ECMO group (100% vs 36.8%, p = 0.004). Although ARDS is uncommon in young trauma patients, it has a high mortality. ECMO therapy was used in a quarter of ARDS cases. AKI and brain edema were the predictors of mortality among ARDS patients. ECMO use did not worsen the outcome in trauma patients; however, the survival was better in those who had severe MLI and ECMO support. Further prospective study is needed to define the appropriate selection criteria for the use of ECMO to optimize the outcomes in trauma patients.

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National Heart, Lung, and Blood Institute and American Association for Thoracic Surgery Workshop Report: Identifying collaborative clinical research priorities in lung transplantation

Outcomes of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation

AimsAcute right ventricular failure remains a common challenging clinical syndrome in heart transplant (HTx) recipients. While extracorporeal membrane oxygenation (ECMO) is a proven strategy for the treatment of this condition, the outcomes after weaning and during follow up remain understudied. We aimed to evaluate the right-sided heart function in ECMO survivors following HTx.MethodsBetween September 2005 and December 2019, 205 patients with end-stage heart failure who underwent standard orthotopic HTx were enrolled. In total, 68 (33.2%) patients were included in the ECMO group and 137 (66.8%) patients were included in the non-ECMO group.ResultsOf the 68 patients in the ECMO group, 42 (61.8%) were successfully weaned from ECMO. After a median follow-up period of 53 months, there were 25 (59.5%) and 27 (23.7%) deaths in the ECMO and non-ECMO groups (P = 0.023), respectively. Systolic pulmonary artery pressure (SPAP) before discharge (P = 0.003) was the unique predictor of all-cause mortality during follow up. Meanwhile, patients in the ECMO group with more than moderate SPAP increase before discharge had higher mortality than patients in the non-ECMO group without such increase (P = 0.005).ConclusionsRecipient right-sided heart characteristics were strong predictors of ECMO need after HTx. ECMO patients had high mortality in the perioperative and follow-up periods, and the changes in right ventricular function in ECMO patients may be associated with pulmonary vessel injury before and after HTx.

Objective To evaluate the clinical efficacy of extracorporeal membrane oxygenation (ECMO)-assisted liver transplantation of donation after cardiac death (DCD). Methods Clinical data of 36 donors of DCD and 26 recipients undergoing liver transplantation from May 2015 to September 2016 in the Third Affiliated Hospital of Sun Yat-sen University were retrospectively analyzed. Among 36 donors, 29 cases were male and 7 female, aged 11-65 years with a median age of 39 years. Primary diseases: 14 cases of severe craniocerebral trauma, 16 cerebrovascular accidents and 6 ischemic and anoxic diseases. According to whether ECMO was employed, all donors were divided into the ECMO group (n=9) and non-ECMO group (n=27). In the ECMO group, 9 cases presented with obvious hemodynamic instability. All the recipients underwent liver transplantation for the first time. The informed consents of all patients were obtained and the local ethical committee approval was received. All donors completed the liver and kidney donation successfully which were met the Guidelines for Donation after Cardiac Death in China. The warm ischemia time between two groups was statistically compared by t test. The liver and kidney functions were compared by rank sum test. Results One donor in the ECMO group was excluded due to mechanical failure of ECMO, whereas 2 donors in the non-ECMO group were excluded due to prolonged warm ischemia time. The warm ischemia time of donor liver in the ECMO group was (4.8±0.4) min, significantly shorter than (24.1±8.0) minin the non-ECMO group (t=-7.89, P<0.05). The ALT levels at postoperative 5, 7 d, and Scr level at postoperative 7 d in the ECMO group were remarkably lower compared with those in the non-ECMO group (Z=-2.10, -2.14, -2.03; P<0.05). Conclusions ECMO support can shorten the warm ischemia time of the liver and kidney of DCD donors with unstable hemodynamics. The recipients undergoing liver transplantation may obtain good clinical efficacy. Key words: Donor after cardiac death; Liver transplantation; Extracorporeal membrane oxygenation; Prognosis

Outcome of extracorporeal membrane oxygenation use in severe accidental hypothermia with cardiac arrest and circulatory instability: A multicentre, prospective, observational study in Japan (ICE-CRASH study)

Mechanical ventilation and extracorporeal membrane oxygenation as a bridge to lung transplantation: Closing the gap

Use of Extracorporeal Membrane Oxygenation Prior to Lung Transplantation Does Not Jeopardize Short-term Survival

Less Delayed Chest Closure, Systemic Edema, and Postoperative Bleeding in Lung Transplantation Using ECMO, Compared with CPB

Background: In cases of respiratory failure, Lung-Protective Ventilation Strategy (LPVS) which limits ventilator-induced lung injury is recommended. However, CO2 retention is a major impediment for LPVS and Extracorporeal membrane oxygenation (ECMO) supplies enough time to the lungs for rest and recovery. We aimed to find out the connection between ECMO usage and the reduction of mechanical ventilatory values in patients who required ECMO therapy after cardiac surgery due to pulmonary failure. Methods: In this retrospective cohort study, we analyzed 21 consecutive patients receiving a venovenous ECMO for pulmonary failure after cardiac surgery and 19 patients non-ECMO group. Demographic variables including age, gender, predicted body weight, and heart rate and the arterial blood gas analysis data, mechanical ventilator parameters and clinical outcomes were derived from institutional database. Results: The mean age of the patients was 55.57 years and ECMO patients were younger than non-ECMO group patients (p=0.005). The other descriptive variables and clinical parameters did not differ between groups statistically. The mechanical ventilator parameters and arterial blood gas analysis were worse in the ECMO group before the procedure (p &lt;0.001) whereas improvement in data was more significant in the ECMO group after the procedure (p&lt;0.001 in Pplateau and PaO2) . The patients in the non-ECMO group stayed longer in hospital (35.68 days vs 16.9 days) and in ICU (31.11 days vs 13.33 days) than the patients in the ECMO group. The duration of the mechanical ventilatory support did not differ between groups. Conclusion: The intensivists had a big dilemma involving the balance between maintaining a sensible blood-gas exchange and protecting the lung from adverse effects of mechanical ventilatory support. The extracorporeal life support –ECMO- was advised until the pulmonary failure was resolved. We found that ECMO support was decreasing the high Plateau Pressure and respiratory rate more than the non-ECMO group.