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Objectives: Historically, the perfusion-guided sequence suggests to first transplant the side with lowest lung perfusion. This sequence is thought to limit right ventricular afterload and prevent acute heart failure after first pneumonectomy. As a paradigm shift, we adopted the right-first implantation sequence, irrespective of lung perfusion. The right donor lung generally accommodates a larger proportion of the cardiac output. We hypothesized that the right-first sequence reduces the likelihood of oedema formation in the firstly transplanted graft during second-lung implantation. Our objective was to compare the perfusion-guided and right-first sequence for intraoperative extracorporeal membrane oxygenation (ECMO) need and primary graft dysfunction (PGD)., Methods: A retrospective single-centre cohort study (2008-2021) including double-lung transplant cases (N = 696) started without ECMO was performed. Primary end-points were intraoperative ECMO cannulation and PGD grade 3 (PGD3) at 72 h. Secondary end-points were patient and chronic lung allograft dysfunction-free survival. In cases with native left lung perfusion ≤50% propensity score adjusted comparison of the perfusion-guided and right-first sequence was performed., Results: When left lung perfusion was ≤50%, right-first implantation was done in 219 and left-first in 189 cases. Intraoperative escalation to ECMO support was observed in 10.96% of right-first versus 19.05% of left-first cases (odds ratio 0.448; 95% confidence interval 0.229-0.0.878; P = 0.0193). PGD3 at 72 h was observed in 8.02% of right-first versus 15.64% of left-first cases (0.566; 0.263-1.217; P = 0.1452). Right-first implantation did not affect patient or chronic lung allograft dysfunction-free survival., Conclusions: The right-first implantation sequence in off-pump double-lung transplantation reduces need for intraoperative ECMO cannulation with a trend towards less PGD grade 3., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Use of extracorporeal life support (ECLS) in lung transplantation (LTx) is center dependent. Peri-operative use of ECLS in sequential single LTx (SSLTx) in our department is conservative to avoid specific ECLS-related complications. In this study we describe the incidence and nature of ECLS-related complications in our LTx experience. All transplantations with peri-operative use of ECLS (2010-2020) were retrospectively analyzed. The demographics, the type of ECLS and its indication were described. All complications were divided within prior specified groups (Fig 1, B). Overall the use of ECLS was 22% (156/703 patients) in our patients (mean age of 52 (36-59)). In 84% (131/156) of the patients an arterial cannula was inserted. In 16% (25/156) only venous cannulation was performed. In 7% (11/156) cardiopulmonary bypass (CPB) was applied intra-operatively. Most common indications for LTx (Fig 1, A, C) was pulmonary fibrosis in 38% (60/156). Main indication for ECLS was intra-operative hemodynamic instability in 52% (81/156) (Fig 1, A, D). 16% (25/156) of patients were bridged to LTx on ECLS and 13% (20/156) required prolonged ECLS post-operatively. Thirty day mortality was 6% (9/156). The use of ECLS did not change over time, the overall incidence of patients with at least one complication was 67% (104/156), over the past years it increased from 56% to 78% (Fig 1, A, B). Most common complications were revision for hemothorax in 25% (39/156) and need for continuous renal replacement therapy (CRRT) in 19% (Fig 1, A, E). In our center, we only use ECLS in 22% of our SSLTx population. However, when ECLS is applied, we report a relatively high number of post-operative complications. Based on our results, we need to focus our attention on kidney failure and strategies to manage coagulation. Center experiences are important but larger databases will be necessary to develop uniform approaches and reports on ECLS in LTx. [ABSTRACT FROM AUTHOR]