Intraoperative Cardiopulmonary Support Research Articles

Fifteen-Year Single Center Experience with Lung Transplantation in Pediatric Patients Younger Than 12 Years Old

Purpose Pediatric lung transplantation poses unique challenges, from donor shortage to surgical access, intraoperative cardiopulmonary support and postoperative management. Moreover, experience with pediatric lung transplantation is scarce, especially in patients younger than 12 years old. In this study, we present our 15-year experience with lung transplantation in pediatric patients younger than 12 years old. Methods Records of pediatric (≤18 years old) patients transplanted at our institution between 01/2005 and 10/2020 were retrospectively reviewed. Outcomes were compared between pediatric patients Results During the study period, among the 1,741 lung-transplanted patients, 125 (7%) patients were pediatric, being 43 (34%) patients Conclusion Lung transplantation in patients

Single Lung Transplant Remains a Viable Alternative to Double Lung Transplantation for the Patients with Severe Secondary Pulmonary Hypertension

<h3>Purpose</h3> Whereas double lung transplantation (LTx) is a preferred surgical option for the patients with secondary pulmonary arterial hypertension (SPH: defined as a mean pulmonary artery pressure (mPAP) above 25 mmHg), our institutional experiences have demonstrated the unique values of single LTx for SPH. Here, we review our experiences prioritizing single LTx for SPH in an attempt to optimize their opportunities and decrease mortality while waiting. <h3>Methods</h3> A retrospective review of the LTx database was used to identify patients who underwent single LTx. SPH patients were stratified into mild SPH (mPAP: 25-40 mmHg) and severe SPH (mPAP > 40 mmHg). Recipients without PH transplanted over the same time period were used as controls. Data are reported as severe SPH vs. mild SPH vs. controls. <h3>Results</h3> Three hundred eighteen patients received single LTx between January 2017 and December 2019. There were 217 patients with mild SPH (mPAP of 32 mmHg), 59 patients with severe SPH (mPAP of 46 mmHg) and 42 patients without PH (controls). There were no significant differences among the groups in their patients' characteristics except higher pulmonary vascular resistance noted in severe SPH group and morbid obesity noted in mild and severe SPH groups. While severe SPH group required more intraoperative cardiopulmonary support (37.3% vs. 11.1% vs. 5.0%, <i>p</i> < 0.05), there were no significant differences in major postoperative complications including postoperative duration mechanical ventilation and incidences of severe primary graft dysfunction. Actual survival at 1 year was not significantly different among the groups (93.2% vs. 88.9% vs. 92.9%, <i>p</i> = 0.683). <h3>Conclusion</h3> Our experience supports the option of single LTx for the patients with even severe SPH by utilizing appropriate mechanical circulatory support intraoperatively. In light of the ongoing donor lung shortage, this strategy should be considered for optimizing organ utilization and decreasing waitlist mortality.

Intraoperative management of a hybrid extracorporeal membrane oxygenation circuit for lung transplantation.

The use of extracorporeal circulation (ECC) for intraoperative cardiopulmonary support during lung transplantation has been increasing in the recent years. Our group previously described a novel hybrid extracorporeal membrane oxygenation (ECMO) circuit for use in lung transplantation. Our approach for intraoperative management of our novel hybrid ECMO circuit for lung transplantation is driven by two main goals: The first is to deliver management that ensures an appropriate balance between the native and ECMO cardiac outputs in order to provide a stable environment that promotes attenuation of ischemic-reperfusion injury during implantation. The second is to provide a stable hemodynamic environment that results in an appropriate global perfusion guided by multiple monitors and an organ systems-based approach during implantation. Our novel technique for intraoperative management of this circuit during lung transplantation is described.

Intraoperative Extracorporeal Circulatory Support in Lung Transplantation for Pulmonary Fibrosis

Venous-arterial extracorporeal membrane oxygenation (ECMO) is an established technique for intraoperative cardiopulmonary support in patients undergoing lung transplantation. Patients with pulmonary fibrosis have a higher risk to require it. The aim of this study was to identify risk factors for the need of intraoperative ECMO use. Records of patients undergoing lung transplantation for pulmonary fibrosis at our institution between January 2010 and May 2018 were retrospectively reviewed. Univariate logistic regression analysis was used for statistical identification of risk factors. There were 105 patients (34%) who required intraoperative ECMO support (ECMO+ group), and 203 (66%) did not (ECMO- group). Preoperative proof of pulmonary hypertension was identified as a risk factor for intraoperative ECMO support (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2-6.5; P < .01). Revealed mean pulmonary arterial pressure values exceeding 50 mm Hg and pulmonary vascular resistance values exceeding 9.4 Wood units were identified as risk factors for the need of intraoperative ECMO use with a prediction probability of 70%. Increased recipient body surface area (OR, 0.2; 95% CI, 0.1-0.5; P < .01) emerged as a protective factor against intraoperative ECMO (Hosmer-Lemeshow statistic, P= .71) as well as higher cardiac output (OR, 0.7; 95% CI, 0.6-0.9; P < .01). The postoperative course was more complicated in the ECMO+ group, whereas survival at 5 years did not differ among groups (70% vs 69%, P= .79). Pulmonary hypertension with elevated pulmonary vascular resistance values predicts the need of intraoperative ECMO in patients receiving lung transplantation for pulmonary fibrosis. Although the postoperative course was more complicated in the ECMO+ group, long-term survival did not differ significantly.

Long-term outcomes after intraoperative extracorporeal membrane oxygenation during lung transplantation

Over the past decade, extracorporeal membrane oxygenation (ECMO) has replaced cardiopulmonary bypass (CPB) for cardiopulmonary support during lung transplantation at our institution. In this study, we present our experience using intraoperative ECMO in isolated lung transplantation and evaluate its impact on long-term graft function and survival. All patients undergoing isolated lung transplantation with or without ECMO support between January 2010 and June 2019 were evaluated. Patients transplanted using CPB were excluded. Peri-operative and follow-up results from our database and patient charts were analyzed. Follow-up continued until September 1, 2019 (median, 3.34 years). In total, 311 of 1,161 lung transplant recipients (27%) received intraoperative ECMO, with 24 (2%) patients further requiring CPB. None of the remaining 826 (71%) patients required intraoperative cardiopulmonary support. ECMO patients exhibited higher pre-transplant surgical risk profiles and endured more complicated early post-operative courses than those without ECMO (in-hospital mortality, 10.9% vs 2.3%; p < 0.001). Inevitably, this resulted in poorer overall graft survival among ECMO recipients (p = 0.0025). However, correcting for patients surviving to hospital discharge, no difference in survival between groups was observed (5-year survival, 71% vs 72%; p = 0.56). Similarly, freedom from chronic lung allograft dysfunction, biopsy-confirmed cellular rejection, or need for pulsed-steroid therapy did not differ between the groups (p = 0.99, p = 0.78, and p = 0.93, respectively). Compared with patients not requiring cardiopulmonary support, ECMO recipients endured a more complicated peri-operative and early post-operative course. However, among those surviving to hospital discharge, no differences in long-term complications or outcomes were observed.

‘Side-Mismatched’ Single Lung Transplantation Does Not Compromise the Transplant Outcomes

Purpose There are controversies regarding which side of the lungs, under-perfused versus over-perfused to be replaced when performing single lung transplantation (LTx). Theoretically, under-perfused lung appears to be better replaced rather than over-perfused lung; however, occasionally over-perfused lung is chosen due to limited organ availability, size discrepancy between the sides, or anatomical complexity, and this is recognized as ‘side-mismatching’ in single LTx. This study aims at evaluating the impact of side-mismatching on transplant outcomes. Methods Graft side-mismatching was defined with a prospectively designed formula using baseline quantitative lung perfusion scan data, and the patients who underwent single LTx between January 2016 and June 2018 were stratified as either side-matched or side-mismatched. A retrospective review of the LTx database was used to obtain short- and mid-term outcomes as well as complications for those patients. Results Two hundred eighteen patients received single LTx between January 2016 and June 2018. Out of these, there were a total of 18 patients had a side-mismatched graft while those with a side-matched graft over the same time period were used as controls. There were no significant differences between the groups in their patients’ characteristics except more patients with age above 70 years old and less patients with secondary pulmonary hypertension noted in the side-mismatched group. While the size-mismatched group consisted of more patients who underwent right single than left single LTx and required more intraoperative cardiopulmonary support (25% vs. 8.2%, p<0.05), there were no significant differences in most postoperative major complications including duration mechanical ventilation and incidences of severe primary graft dysfunction. Actual survival at 1 year was not significantly different among the groups (86% vs. 88%). Conclusion Our data suggest that there is no evident increased risk or compromised post-transplant outcomes in performing side-mismatched single LTx when appropriate lung graft as well as intraoperative cardiopulmonary support is chosen. This strategy could optimize organ utilization increasing effective organ supply and decreasing waitlist mortality. In addition, this may contribute to avoiding the surgical or anatomical complexity leading to improved transplant outcomes. There are controversies regarding which side of the lungs, under-perfused versus over-perfused to be replaced when performing single lung transplantation (LTx). Theoretically, under-perfused lung appears to be better replaced rather than over-perfused lung; however, occasionally over-perfused lung is chosen due to limited organ availability, size discrepancy between the sides, or anatomical complexity, and this is recognized as ‘side-mismatching’ in single LTx. This study aims at evaluating the impact of side-mismatching on transplant outcomes. Graft side-mismatching was defined with a prospectively designed formula using baseline quantitative lung perfusion scan data, and the patients who underwent single LTx between January 2016 and June 2018 were stratified as either side-matched or side-mismatched. A retrospective review of the LTx database was used to obtain short- and mid-term outcomes as well as complications for those patients. Two hundred eighteen patients received single LTx between January 2016 and June 2018. Out of these, there were a total of 18 patients had a side-mismatched graft while those with a side-matched graft over the same time period were used as controls. There were no significant differences between the groups in their patients’ characteristics except more patients with age above 70 years old and less patients with secondary pulmonary hypertension noted in the side-mismatched group. While the size-mismatched group consisted of more patients who underwent right single than left single LTx and required more intraoperative cardiopulmonary support (25% vs. 8.2%, p<0.05), there were no significant differences in most postoperative major complications including duration mechanical ventilation and incidences of severe primary graft dysfunction. Actual survival at 1 year was not significantly different among the groups (86% vs. 88%). Our data suggest that there is no evident increased risk or compromised post-transplant outcomes in performing side-mismatched single LTx when appropriate lung graft as well as intraoperative cardiopulmonary support is chosen. This strategy could optimize organ utilization increasing effective organ supply and decreasing waitlist mortality. In addition, this may contribute to avoiding the surgical or anatomical complexity leading to improved transplant outcomes.

Need for and Outcomes of Intraoperative Extracorporeal Circulatory Support in Lung Transplantation for Pulmonary Fibrosis

Purpose V-a extracorporeal membrane oxygenation (ECMO) has been successfully used for intraoperative cardiopulmonary support in patients undergoing lung transplantation. Especially patients with lung fibrosis are at risk to require intraoperative v-a ECMO. Aim of this study was to identify predisposing risk factors for intraoperative ECMO support and postoperative outcomes in this cohort of patients. Methods Patients transplanted for lung fibrosis between January 2010 and May 2018 were included into the study. Patients transplanted on v-a ECMO formed group A, the remaining, group B. Follow-up amounted to a mean of 37±27 months. Multivariate forward and backward logistic regression analysis was used to identify risk factors for ECMO. Results Among the 1042 lung-transplanted patients, 313 (30%) patients underwent bilateral transplantation for lung fibrosis. Five patients were excluded as they received conventional cardiopulmonary support due to different resaons. Among the remaining 308 patients, 109 (35%) patients formed group A, 199 (65%), group B. Presence of pulmonary hypertension (OR 3.1; 95%CI 1.8-5.3, p Conclusion Smaller recipient BSA, pulmonary hypertension with high PVR values and evidence of a dilated and hypertrophic right ventricle can predict the need for intraoperative ECMO in patients transplanted for lung fibrosis. Although the postoperative course was more complicated in group A than B, long-term survival did not differ between groups.

Extracorporeal lung support.

The applications for extracorporeal membrane oxygenation for lung support are constantly evolving. This review highlights fundamental concepts in extracorporeal lung support and describes directions for future research. Since the 1950s, extracorporeal lung support has experienced continuous advancements in circuit design and safety in acute respiratory distress syndrome, chronic obstructive pulmonary disease exacerbations, as a bridge to transplantation, intraoperative cardiopulmonary support, and for transportation to referral centers. Patients on extracorporeal membrane oxygenation are now capable of being awake, extubated, and ambulatory for accelerated recovery or optimization for transplantation. Extracorporeal lung support is a safe and an easily implemented intervention for refractory respiratory failure. Recent advances have extended its use beyond acute illnesses and the developments for chronic support will facilitate the development of durable devices and possible artificial lung development.

(690) - Intraoperative Cardiopulmonary Support With Extracorporeal Membrane Oxygenation in Lung Transplantation: Favorable Outcomes in High Risk Patients

(690) - Intraoperative Cardiopulmonary Support With Extracorporeal Membrane Oxygenation in Lung Transplantation: Favorable Outcomes in High Risk Patients

EXPERIENCE WITH APPLICATION OF EXTRACORPOREAL MEMBRANE OXYGENATION IN DOUBLE LUNG TRANSPLANTATION

The most reliable intraoperative mechanical extracorporeal support is conventional сardiopulmonary bypass (CPB). However, CPB increases a risk of intraoperative bleeding and primary graft dysfunction. ECMO is more benefi cial method of intraoperative cardiopulmonary support than CPB in LTx. Aim . 10 LTx were retrospectively analyzed in the period from 01.2012 till 01.2014. Methods . Indications for ECMO were acute grafts edema after reperfusion (n = 4, group I). In group II (n = 6) indications for ECMO were severe hypoxia ( РаО 2 and FiO 2 ratio &lt; 1,0) and/or acidosis (pH &lt; 7,2) during one lung ventilation. We used central type of veno-arterial ECMO: right atrium to ascending aorta. Results . Intraoperative ECMO lasted 4,1 ± 1,0 hours in group I and 8,5 ± 0,7 hours in group II. ECMO was prolonged into postoperative period in all patients from group I due to primary graft dysfunction. Application of ECMO in group II enabled to stabilize gas exchange and circulation as well as to decrease pulmonary arterial pressure in the time of reperfusion. ECMO was fi nished just after transplantation in group II. The 1-year survival in group I and II was 75,0 and 83,3%, respectively. Conclusion . Central veno-arterial ECMO is an adequate method of intraoperative cardiopulmonary support in LTx. It prevents postreperfusion edema of the lung grafts.