Search

Extending selection criteria to face donor organ shortage in heart transplantation (HTx) may increase the risk of mortality. Ex-vivo normothermic perfusion (EVP) limits ischemic time allowing assessment of graft function. We investigated the outcome of HTx in 80 high-risk recipients transplanted with marginal donor and EVP-preserved grafts, from 2016 to 2021. The recipients median age was 57 years (range, 13-75), with chronic renal failure in 61%, impaired liver function in 11% and previous cardiac surgery in 90%; 80% were mechanically supported. Median RADIAL score was 3. Mean graft ischemic time was 118 ± 25 min, "out-of-body" time 420 ± 66 min and median cardiopulmonary bypass (CPB) time 228 min (126-416). In-hospital mortality was 11% and ≥moderate primary graft dysfunction 16%. At univariable analysis, CPB time and high central venous pressure were risk factors for mortality. Actuarial survival at 1 and 3 years was 83% ± 4%, and 72% ± 7%, with a median follow-up of 16 months (range 2-43). Recipient and donor ages, pre-HTx extracorporeal life support and intra-aortic balloon pump were risk factors for late mortality. In conclusion, the use of EVP allows extension of the graft pool by recruitment of marginal donors to successfully perform HTx even in high-risk recipients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Sponga, Vendramin, Salman, Ferrara, De Manna, Lechiancole, Warnecke, Dralov, Haverich, Ius, Bortolotti, Livi and Avsar.)

Objective: To clarify the relationship between the use of extracorporeal life support during lung transplantation and severe primary graft dysfunction (PGD), we developed and analyzed a novel multicenter international registry., Methods: The Extracorporeal Life Support in Lung Transplantation Registry includes double-lung transplants performed at 8 high-volume centers (>40/year). Multiorgan transplants were excluded. We defined severe PGD as grade 3 PGD (PGD3) observed 48 or 72 hours after reperfusion. Modes of support were no extracorporeal life support (off-pump), extracorporeal membrane oxygenation (ECMO), and cardiopulmonary bypass (CPB). To assess the association between mode of support and PGD3, we adjusted for demographic and intraoperative factors with a stepwise, mixed selection, multivariable regression model, ending with 10 covariates in the final model., Results: We analyzed 852 transplants performed between January 2016 and March 2020: 422 (50%) off-pump, 273 (32%) ECMO, and 157 (18%) CPB cases. PGD3 rates at time point 48-72 were 12.1% (51 out of 422) for off-pump, 28.9% for ECMO (79 out of 273), and 42.7% (67 out of 157) for CPB. The adjusted model resulted in the following risk profile for PGD3: CPB versus ECMO odds ratio, 1.89 (95% CI, 1.05-3.41; P = .033), CPB versus off-pump odds ratio, 4.24 (95% CI, 2.24-8.04; P < .001), and ECMO versus off-pump odds ratio, 2.24 (95% CI, 1.38-3.65; P = .001)., Conclusions: Venoarterial ECMO is increasingly used at high-volume centers to support complex transplant recipients during double-lung transplantation. This practice is associated with more risk of PGD3 than off-pump transplantation but less risk than CPB. When extracorporeal life support is required during lung transplantation, ECMO may be the preferable approach when feasible., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: 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., Methods: 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., Results: 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)., Conclusions: 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., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: 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., Methods: 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)., Results: 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)., Conclusions: 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., (Copyright © 2020 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: Extracorporeal membrane oxygenation (ECMO) has an important role in bridging patients to lung transplantation. In this study, we present our experience with pretransplant ECMO during the last 7 years and investigate its impact on graft outcomes., Methods: Records of all lung-transplanted patients at our institution between January 2010 and April 2017 were retrospectively reviewed. Graft survival was compared between patients who required pretransplant ECMO (pre-Tx ECMO+) and patients who did not (pre-Tx ECMO-). Risk factors for in-hospital mortality and graft survival were identified using a binary logistic regression and the Cox regression analyses, respectively., Results: Among the 917 patients transplanted during the study period, 68 (7%) required ECMO as a bridge to transplantation [awake strategy, n = 57 (84%) patients]. Median bridging time was 9 days. Among pre-Tx ECMO+ patients, the need for haemodialysis at any point during bridging emerged as an independent risk factor for in-hospital mortality (odds ratio 7.79, 95% confidence interval 1.21-50.24; P = 0.031). Although in-hospital mortality was significantly higher in pre-Tx ECMO+ versus pre-Tx ECMO- patients (15% vs 5%, P = 0.003), overall graft survival did not differ between groups (79% vs 90% and 61% vs 68% at 1 and 5 years, respectively, P = 0.13). Pretransplant ECMO did not emerge as a risk factor for graft survival in the multivariable analysis., Conclusions: If applied in selected patients in a high-volume centre, pretransplant ECMO as a bridge to transplantation results in impaired, but still high in-hospital, survival and does not impact graft survival.

Objectives: In severe pulmonary hypertension, diastolic dysfunction of the left ventricle causes significant morbidity and mortality after lung transplantation, which may be successfully reversed using a protocol based on perioperative veno-arterial extracorporeal membrane oxygenation (ECMO) and early extubation. Here, we present echocardiographic data and mid-term outcomes., Methods: The records of lung transplanted patients at our institution between May 2010 and January 2016 were retrospectively reviewed. Echocardiography data were collected preoperatively, at discharge, 3 and 12 months after transplantation., Results: During the study period, 717 patients underwent lung transplantation at our institution, 38 (5%) patients being transplanted for severe pulmonary hypertension. All patients underwent bilateral lung transplantation on veno-arterial ECMO cannulated in the groin, through a sternum sparing thoracotomy in 36 (95%) patients. Extubation was performed early, after a median of 2 days, and awake ECMO was extended for at least 5 days after transplantation. The survival at 3 months, 1 year and 5 years was not different in comparison to patients transplanted for other underlying diseases ( P  = 0.45). At 1 year, tricuspid valve regurgitation had disappeared in all patients. The median of the left ventricular end-diastolic dimension improved from 40 (32-44) mm preoperatively to 45 (44-47) mm at 12 months after lung transplantation ( P  < 0.05). The median of the proximal right ventricular outflow diameter decreased to 25 (23-27) mm after 12 months, compared to 48 (43-51) mm preoperatively ( P  < 0.05)., Conclusions: The routine application of a prophylactic postoperative veno-arterial ECMO protocol in patients with severe pulmonary hypertension undergoing lung transplantation decreases postoperative mortality and favours achievement of normal cardiac function after 1 year., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

This single-center study examines the incidence, etiology, and outcomes associated with prolonged mechanical ventilation (PMV), defined as time to definite spontaneous ventilation >21 days after double lung transplantation (LTx). A total of 690 LTx recipients between January 2005 and December 2012 were analyzed. PMV was necessary in 95 (13.8%) patients with decreasing incidence during the observation period (p < 0.001). Independent predictors of PMV were renal replacement therapy (odds ratio [OR] 11.13 [95% CI, 5.82-21.29], p < 0.001), anastomotic dehiscence (OR 8.74 [95% CI 2.42-31.58], p = 0.001), autoimmune comorbidity (OR 5.52 [95% CI 1.86-16.41], p = 0.002), and postoperative neurologic complications (OR 5.03 [95% CI 1.98-12.81], p = 0.001), among others. Overall 1-year survival was 86.0% (90.4% for LTx between 2010 and 2012); it was 60.7% after PMV and 90.0% in controls (p < 0.001). Conditional long-term outcome among hospital survivors, however, did not differ between the groups (p = 0.78). Multivariate analysis identified renal replacement therapy (hazard ratio [HR] 3.55 [95% CI 2.40-5.25], p < 0.001), post-LTx extracorporeal membrane oxygenation (HR 3.47 [95% CI 2.06-5.83], p < 0.001), and prolonged inotropic support (HR 1.95 [95% CI 1.39-2.75], p < 0.001), among others, as independent predictors of mortality. In conclusion, PMV complicated 14% of LTx procedures and, although associated with increased in-hospital mortality, outcomes among patients surviving to hospital discharge were unaffected., (© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.)

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., (Copyright © 2016 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: Patients with respiratory failure may benefit from veno-venous and veno-arterial extracorporeal membrane oxygenation (ECMO) support. We report on our initial experience of veno-veno-arterial (v-v-a) ECMO in patients with respiratory failure., Methods: Between January 2012 and February 2014, 406 patients required ECMO support at our institution. Here, we retrospectively analysed the characteristics and outcomes of patients commenced on either veno-venous or veno-arterial ECMO due to respiratory failure, and then switched to v-v-a ECMO., Results: Ten (2%) patients proceeded to v-v-a ECMO. The underlying conditions were acute respiratory distress syndrome (n = 3), end-stage pulmonary fibrosis (n = 5) and respiratory failure after major thoracic surgery (n = 1) and Caesarean section (n = 1). In all of these patients, ECMO was initially started as veno-venous (n = 9) or veno-arterial (n = 1) ECMO but was switched to a veno-veno-arterial (v-v-a) approach after a mean of 2 (range, 0-7) days. Reasons for switching were: haemodynamic instability (right heart failure, n = 5; pericardial tamponade, n = 1; severe mitral valve regurgitation, n = 1; haemodynamic instability following cardiopulmonary resuscitation, n = 1 and evidence of previously unknown atrial septal defect with pulmonary hypertension and Eisenmenger syndrome, n = 1) and upper-body hypoxaemia (n = 1). ECMO-related complications were bleeding (n = 3) and leg ischaemia (n = 2). Seven patients were successfully taken off ECMO with 4 being bridged to recovery and a further 3 to lung transplantation after a mean of 11 (range, 9-18) days. Five patients survived until hospital discharge and all of them were alive at the end of the follow-up., Conclusions: Veno-veno-arterial ECMO is a technically feasible rescue strategy in treating patients presenting with combined respiratory and haemodynamic failure., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Severe acute heart failure requires immediate intensive care unit (ICU) treatment, but prognosis and outcome of further treatment regimens largely depends on the preprocedural status of the patient. Especially, multiorgan failure including mechanical ventilation are unfavorable predictors of clinical outcome. Here, we report a strategy of immediate initiation of extracorporeal life support (ECLS) in awake and spontaneously breathing patients with acute heart failure to achieve early multiorgan recovery and gain sufficient time for further treatment planning. Twenty-three patients with severe cardiac failure refractory to standard medical management underwent ECLS treatment, after first clinical signs of cardiac failure appeared to avoid mechanical ventilation. Hemodynamic parameters and renal and liver functions were monitored. Outcome at 1 and 6 months was determined. Patients 46.1 ± 15.5 years of age were placed on ECLS due to various underlying diagnosis: ischemic heart disease (n = 6), dilatative cardiomyopathy (n = 4), myocarditis (n = 2), graft failure following heart transplantation (n = 6), or other diseases (n = 5). ECLS lasted 11.9 ± 12.9 days. Hemodynamic stabilization was achieved immediately after ECLS initiation. Vasopressors were reduced subsequently and the cardiac situation improved indicated by central venous saturation, which increased from 38.5 ± 11.3% before to 74.26 ± 8.4% (P < 0.0001) 24 h after ECLS initiation. Similarly, serum lactate levels decreased from 4.7 ± 4.6 to 1.7 ± 1.51 mmol/L (P = 0.003). Cumulative 30-day survival was 87.5%, and 6-month survival was 70.8%. In acute cardiac failure, early ECLS treatment is a safe, feasible treatment in awake patients allowing a gain of time for final decision. Moreover, this strategy avoids complications associated with sedation and mechanical ventilation and leads to recovery of secondary organ function, enabling destination therapy., (Copyright © 2015 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background: Bilateral lung transplantation (BLTx) is an established treatment for end-stage pulmonary hypertension (PH). Ventilator weaning failure and death are more common as in BLTx for other indications. We hypothesized that left ventricular (LV) dysfunction is the main cause of early postoperative morbidity or mortality and investigated a weaning strategy using awake venoarterial extracorporeal membrane oxygenation (ECMO)., Methods: In 23 BLTx for severe PH, ECMO used during BLTx was continued for a minimum of 5 days (BLTx-ECMO group). Echocardiography, left atrial (LA) and Swan-Ganz catheters were used for monitoring. Early extubation after transplantation was attempted under continued ECMO., Results: Preoperatively, all patients had severely reduced cardiac index (mean, 2.1 L/min/m2). On postoperative day 2, reduction of ECMO flow resulted in increasing LA and decreasing systemic blood pressures. On the day of ECMO explantation (median, postoperative day 8), LV diameter had increased; LA and blood pressures remained stable. Survival rates at 3 and 12 months were 100% and 96%, respectively. Data were compared to two historic control groups of BLTx without ECMO (BLTx ventilation) or combined heart-lung transplantation for severe PH., Conclusion: Early after BLTx for severe PH, the LV may be unable to handle normalized LV preload. This can be effectively bridged with awake venoarterial ECMO.

Background: Paraquat is a highly toxic herbicide, which not only leads to acute organ damage, but also to pulmonary fibrosis. There are only anecdotal reports of rescue lung transplantation, as paraquat is stored and only slowly released from different tissues. Bridging the time to complete depletion of paraquat from the body could render this exceptional therapy strategy possible, but not much is known on the time interval after which transplantation can safely be performed., Case Presentation: We report on a case of accidental paraquat poisoning in a 23 years old Caucasian man, who developed respiratory failure due to pulmonary fibrosis. The patient was listed for high urgency lung transplantion, and extracorporeal membrane oxygenation was implemented to bridge the time to transplantation. The patient died 32 days after paraquat ingestion, before a suitable donor organ was found. In postmortem tissue specimen, no paraquat was detectable anymore., Conclusion: This case report indicates that complete elimination of paraquat after oral ingestion of a lethal dose is achievable. The determined time frame for this complete elimination might be relevant for patients, in which lung transplantation is considered.

In patients awaiting LuTx, MV and ECMO are often the last ways to create a bridge to LuTx. Both interventions are associated with a poor posttransplant outcome and survival rate. To improve the results of these patients, new "bridging-strategies" are necessary. Recent reports demonstrate promising results for the concept of "awake ECMO" in adult patients. To date, no data on this approach in pediatric patients have been available. We therefore describe the use of VV-ECMO as a treatment strategy for RF in awake pediatric patients. It presents our experiences with the first three children treated using this new concept. Mean amount of time on ECMO was 44 days (range, 11.5-109 days). Two patients were successfully bridged to their LuTx. Both are still alive without any recurrences (24 and three months following LuTx). One patient died before a further LuTx after 109 days on ECMO due to adenoviral infection. Although reintubation was necessary in two patients, and total time being awake while on ECMO was <50%, we conclude that the concept of "awake VV-ECMO" is feasible for the treatment of RF and can be used as a "bridging therapy" to LuTx., (Copyright © 2012 John Wiley & Sons A/S.)

Objectives: Patients requiring extracorporeal cardiorespiratory support during lung transplantation can be treated with conventional cardiopulmonary bypass (CPB) or venoarterial extracorporeal membrane oxygenation (ECMO). In a retrospective analysis, we compared the postoperative course and outcomes of patients treated using these approaches., Methods: Between August 2008 and September 2011, 92 consecutive patients underwent lung transplantation with extracorporeal support (CPB group, n = 46; and, since February 2010, ECMO group, n = 46) at our institution. We evaluated survival, secondary organ failure, bleeding complications, and the need for blood and platelet transfusions in these 2 patient populations., Results: Intraoperatively, the CPB group required more packed red blood cell transfusions (12 ± 11 vs 7 ± 9 U; P = .01) and platelet concentrates (2.5 ± 1.6 vs 1.5 ± 1 U; P < .01) than the ECMO group. In-hospital mortality (39% vs 13%; P = .004), the need for hemodialysis (48% vs 13%; P < .01), and new postoperative ECMO support (26% vs 4%; P < .01) were greater in the CPB group than in the ECMO group, respectively. After propensity score analysis, multivariate analysis identified retransplantation (odds ratio, 7; 95% confidence interval, 1-43; P = .034) and transplantation with CPB support (odds ratio, 4.9; 95% confidence interval, 1.2-20; P = .026) as independent risk factors for in-hospital mortality. The survival rate at 3, 9, and 12 months was 70%, 59%, and 56% in the CPB group and 87%, 81%, and 81% in the ECMO group (P = .004)., Conclusions: Intraoperative ECMO allows for better periprocedural management and reduced postoperative complications and confers a survival benefit compared with CPB, mainly because of lower in-hospital mortality. It is now the standard of care in our lung transplantation program., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Rationale: The use of extracorporeal membrane oxygenation (ECMO) in patients who are awake and spontaneously breathing may represent a novel bridging strategy toward lung transplantation (LuTx)., Objectives: To evaluate the outcomes of patients treated with the "awake ECMO" concept as bridge to transplantation., Methods: We performed a retrospective, single-center, intention-to-treat analysis of consecutive LuTx candidates with terminal respiratory or cardiopulmonary failure receiving awake ECMO support. The outcomes were compared with a historical control group of patients treated with conventional mechanical ventilation (MV group) as bridge to transplant., Measurements and Main Results: Twenty-six patients (58% female; median age, 44 yr; range, 23-62) were included in the awake ECMO group and 34 patients (59% female; median age, 36 yr; range, 18-59) in the MV group. The duration of ECMO support or MV, respectively, was comparable in both groups (awake ECMO: median, 9 d; range, 1-45. MV: median, 15 d; range, 1-71; P = 0.25). Six (23%) of 26 patients in the awake ECMO group and 10 (29%) of 34 patients in the MV group died before a donor organ was available (P = 0.20). Survival at 6 months after LuTx was 80% in the awake ECMO group versus 50% in the MV group (P = 0.02). Patients in the awake ECMO group required shorter postoperative MV (P = 0.04) and showed a trend toward a shorter postoperative hospital stay (P = 0.06)., Conclusions: ECMO support in patients who are awake and nonintubated represents a promising bridging strategy, which should be further evaluated to determine its role in patients with end-stage lung disease awaiting LuTx.

Background: Extracorporeal membrane oxygenation (ECMO) is a well-established treatment for severe cardiopulmonary failure. Patients undergoing ECMO support through femoral vessels are prone to vascular complications. The aim of this study was to evaluate such complications to outline basic technical principles for their prevention., Methods: From January 2005 to December 2009, 174 patients underwent ECMO support through cannulation of the femoral vessels. The primary outcome was any vascular complication. Secondary outcomes were 30-day mortality and 1-year survival. A logistic regression analysis including ECMO duration, peripheral arterial disease, ECMO access (percutaneous versus open), and diabetes mellitus identified predictors for vascular complications., Results: The venoarterial mode was used in 143 patients (82%), and venovenous in 31 patients (18%). Of the 17 (10%) observed vascular complications, 15 (88%) occurred in patients with venoarterial access, whereas 2 (12%) occurred after venovenous access (p=0.50) Two patients who had extremity ischemia required limb amputation. Thirty-day mortality and 1-year survival rates were 63% and 26%, respectively. Peripheral arterial disease was the only strong predictor of vascular complications (odds ratio, 6.95; 95% confidence interval, 1.89 to 25.59; p=0.003). Vascular complications were not associated with early or late mortality., Conclusions: The incidence of vascular complications in venovenous cannulation was low, whereas in arterial cannulation, it is still considerable. Peripheral arterial disease remains a risk factor, and early involvement of vascular surgeons for open vascular exposure or alternative vascular access sites can be recommended. Vascular complications after ECMO support are not associated with higher mortality rates., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We report on the use of veno-arterial extracorporeal membrane oxygenation (ECMO) as a bridging strategy to lung transplantation in awake and spontaneously breathing patients. All five patients described in this series presented with cardiopulmonary failure due to pulmonary hypertension with or without concomitant lung disease. ECMO insertion was performed under local anesthesia without sedation and resulted in immediate stabilization of hemodynamics and gas exchange as well as recovery from secondary organ dysfunction. Two patients later required endotracheal intubation because of bleeding complications and both of them eventually died. The other three patients remained awake on ECMO support for 18-35 days until the time of transplantation. These patients were able to breathe spontaneously, to eat and drink, and they received passive and active physiotherapy as well as psychological support. All of them made a full recovery after transplantation, which demonstrates the feasibility of using ECMO support in nonintubated patients with cardiopulmonary failure as a bridging strategy to lung transplantation., (© 2010 The Authors Journal compilation © 2010 The American Society of Transplantation and the American Society of Transplant Surgeons.)

At our institution, patients with severe pulmonary arterial hypertension (sPAH) undergo lung transplantation using a protocol based on postoperative extension of intraoperatively initiated veno-arterial extracorporeal membrane oxygenation (vaECMO) support. Here we present our 12-year experience with this protocol. Records of patients transplanted at our institution between May 2010 and September 2022 were retrospectively reviewed. Outcomes were compared between sPAH patients and patients transplanted for all the other indications. Prevalence of primary graft dysfunction (PGD) grade 3 and intensive care unit (ICU) stay time were compared using Chi-squared test and Mann-Whitney-U test, respectively. Graft survival and freedom from chronic lung allograft dysfunction (CLAD) were compared using Kaplan-Meyer analysis with the log-rank test and were further analysed by propensity score analysis. Among the 1419 lung transplanted patients, 90 (6.3%) were transplanted for sPAH and 1329 (93.6%) for other indications. Patients with sPAH were younger (33 vs. 53 years, p<0.0001) and prevalence of PGD grade 3 was higher at 24h (21% vs. 5%; p<0.0001), 48h (22% vs 5%; p<0.0001) and 72h (22 vs. 4%; p<0.0001) in comparison to control patients. Median postoperative ICU stay time was longer in sPAH patients (13 vs. 2 days; p<0.0001). 1-, 6- and 12-year survival (86.5% vs. 90.8%, 61.2% vs. 67.9%, 52% vs. 48.1% p=0.347), freedom from CLAD during follow up (96.8% vs. 96.6%, 65.8% vs. 66.1%, 57.3% vs. 54.9% p=0.955) and survival conditioned to hospital discharge (94.9% vs. 95.1%, 73% vs. 73.3%, 65.5% vs. 53% p=0.556) did not differ in sPAH vs. control patients. According to propensity score analysis, sPAH did not appear be associated with increased mortality, CLAD or mortality conditioned to hospital discharge. A protocol based on postoperatively extended intraoperative vaECMO support allows safe transplantation of patients with sPAH. Despite increased morbidity in the early postoperative period, long-term survival and freedom from CLAD were not reduced and negatively affected by sPAH. [ABSTRACT FROM AUTHOR]

Donation after circulatory death (DCD) is propagated to expand the lung transplant (LTx) organ donor pool. Using the International ECLS Registry database, we compared DCD vs DBD LTx survival in the context of intraoperative extracorporeal life support (ECLS). We hypothesize comparable survival outcomes and ECLS usage between donor groups. Patients undergoing double-lung transplant were included from multiple institutions in US & Europe. Patients were stratified by donor type (DCD, DBD). Differences between groups in ECLS usage (yes/no) were analyzed with Chi-square testing or Fisher's exact test. Donor, recipient, and procedural characteristics, including the primary outcome of post-operative survival, were analyzed using Wilcoxon rank sum test or Chi-square testing. Propensity matching was used with Kaplan-Meier survival curves and log-rank testing to assess mortality between groups with and without ECLS. Analysis of differences in patient/donor demographics, pre-operative, intra-operative and post-operative ECLS usage, post-operative complications, and patient survival will be used to compare the DCD and DBD donor groups. A total of 866 double lung transplantations (DLT), 72 DCD and 794 DBD cases, were preliminarily analyzed. DCD had older mean donor age (p=0.003), and higher post-operative pneumonia rates in DCD (p=0.01). Groups were different in the type of intra-operative ECLS support required (CPB, ECMO, Modified bypass) (p=0.014), total ischemic time (p=0.0001), and post-op ECMO (p=0.06). Mortality analysis showed no increased risk for DCD vs DBD groups before discharge (HR 1.31; CI- 0.43, 3.96; p=0.63), at 90-days (HR 1.49; CI- 0.35, 6.31; p=0.58), and 1-year (HR 0.93, CI-0.33, 2.60; p=0.89). Figure shows KM curves before and after propensity matching with/without ECLS. Further analysis will be done as the ECLS Registry patient volume increases. [ABSTRACT FROM AUTHOR]

Cold ischemic time (CIT) may adversely affect clinical outcomes after lung transplantation (LTx). Most centers restrict CIT to less than 6-8 hours. However, to improve donor utilization, centers are increasingly pushing the envelope of CIT. To clarify the effect of CIT on graft function and clinical outcomes, we analyzed the international multicenter ECLS in LTx registry. the ECLS registry collects LTx data from 6 US and 2 European centers between January 2016 and March 2020. Single LTx, ex vivo lung perfusion, and multiple organ transplants were excluded. CIT was analyzed as a continuous variable and divided in balanced tertiles. The reperfusion of the second lung was considered the end of the CIT. Models were adjusted by 11 clinical factors. Our endpoints were PGD at T0, T24, T48 and T72 hours according to the 2016 ISHLT consensus. Length of stay, death within 90 days and at one year of follow-up was investigated. A univariate and multivariate analysis was performed. Pearson correlation analysis was used to assess effect of CIT on length of stay (LOS). The inclusion criteria were met by 798 patients. The mean and median CIT was 418 and 397 min, respectively. Adjusted analysis suggests that total CIT was not associated with PGD grade 3 at 48 and 72 hours (OR1.24, 0.87-1.75). However, CIT was associated with several other markers of graft dysfunction and resource utilization including PGD3 T0 (OR1.5, 1.06-2.13), tracheostomy (OR1.93, 1.3-2.87), post-op ECMO (OR3.47, 2.21-5.45), renal failure requiring dialysis (OR1.8, 1.13-2.86), death within 90 days (2.41, 1.42-4.09), death in hospital (OR2.53, 1.47-4.35), and death within one year (OR 2.37, 1.43-3.94). Total ischemic time was also independently associated with LOS (P<0.0001). In a multicenter international registry, increasing CIT was associated with increased PGD at T0, higher postoperative morbidity and worse first year survival. Although patients can be transplanted with extended cold ischemic times when absolutely needed, this practice is associated with greater resource utilization and likely impact on survival. [ABSTRACT FROM AUTHOR]

At our institution, since early 2010, patients with severe pulmonary hypertension have been transplanted using a protocol based on postoperative extension of intraoperatively-started veno-arterial extracorporeal membrane oxygenation (vaECMO) support. Here we present our 10-year experience with bilateral lung transplantation using vaECMO support in patients with severe pulmonary hypertension. Records of patients transplanted at our institution between January 2010 and October 2020 were retrospectively reviewed. Prevalence of primary graft dysfunction (PGD) and ventilation time were compared between patients transplanted for severe pulmonary hypertension vs. patients transplanted for other indications (control group), using Chi-Square test and Mann-Whitney U test, respectively. Graft survival and freedom from chronic lung allograft dysfunction (CLAD), were compared between groups using Kaplan-Meyer analysis with the log-rank test. During the study period, among the 1288 lung transplanted patients at our institution, 85 (6.2%) patients were transplanted for sPAH and 1201 (93.8%) patients for other indications. Patients with severe pulmonary hypertension were younger than control patients (31 vs. 47 years, p<0.0001). Prevalence of PGD grade 3 was higher in sPHT than in the control group at 24h (22% vs. 5%; p<0.0001), 48h (23% vs 5%; p<0.0001) and 72h (24 vs. 4%; p<0.0001). Mean postoperative ventilation time was significantly longer in sPHT than in the control group (11.4 vs. 3.5 days; p<0.0001). 1-, 5- and 10-year overall patient and graft survival (86% vs. 90%, 68% vs. 70%, 54% vs. 57% p=0.769), freedom from CLAD during follow up (97% vs. 96%, 75% vs. 67%, 60% vs. 52% p=0.391) and survival conditioned to hospital discharge (94% vs. 95%, 80% vs. 76%, 69% vs. 64% p=0.328) did not differ between sPHT and control patients. A protocol based on postoperatively-extended intraoperative ECMO support allows safe transplantation of sPHT patients. Despite increased morbidity in the early postoperative period, long-term survival and freedom from CLAD do not differ compared to patients who were transplanted for other indications. [ABSTRACT FROM AUTHOR]

Ex vivo lung perfusion (EVLP) improves organ quality and makes the lungs safe that were previously unsuitable for bilateral lung transplant (BLT). We investigated EVLP utilization in BLT from our ECLS registry and compared the outcome in DCD and DBD. Patient data involving BLT were collected from the National ECLS Registry and stratified by EVLP in DCD and DBD. ECLS usage information was obtained and analyzed with Chi-square testing or Fisher's exact test to determine a relationship with donor groupings in EVLP. Lung transplant procedure details, patient and donor demographics and post-operative survival were analyzed using Wilcoxon rank sum test or Chi-square testing to determine distribution. Kaplan-Meier survival curves with log-rank testing to assess mortality between donor groups with EVLP use. P-values <0.05 were considered statistically significant. Out of 932 BLT, there were total 66 EVLP: 20 DCD and 46 DBD cases. Demographics data showed age:54±14 years, BMI 25 ± 5 kg/m2, 34M, LAS - 44±14, PHTN - 51 patients, prior ECMO - 2, donor age 38 ± 14, donor gender - 38M, total ischemic time - 578±149 min, Use of ECLS - CPB:7, ECMO:26, Modified bypass:8, Off-pump:25, PGD at 48h-72h - 18, Post-op ECMO: VA - 3, VV - 12, VVA - 1. Death before discharge - 9, before 90d - 5, before 1yr - 9. Tracheostomy - 15 patients, post-op pneumonia - 10 patients, median length of stay - 22 days. Unadjusted comparison reveals significant differences in 1yr survival with EVLP vs DBD vs DCD utilization (HR:2.16; CI- 1.00-4.66; p=0.05), but when adjusted, there were no significant differences (HR:0.93; CI- 0.33-2.60; p=0.883). Kaplan-Meier curve showed no statistical significance in DCD and DBD groups when used for EVLP. EVLP utilization did not have any significant effect in survival when used in DCD and DBD transplantation. It suggests EVLP can be safely utilized in both groups thereby increasing the donor pool. [ABSTRACT FROM AUTHOR]

Bilateral thoraco-sternotomy (clamshell), median sternotomy, and sternum-sparing bilateral thoracotomies represent the surgical accesses for lung transplantation. To clarify the effect of surgical exposure on peritransplant clinical outcomes, we analyzed the international multicenter ECLS in lung transplantation (LTx) registry. The ECLS registry collects data from 7 US and 2 European centers. We analyzed adult LTx performed between 01/2016 and 09/2020 and formed three groups according to surgical access (Clamshell Group; Sternotomy Group; Thoracotomy Group). Categorical and continuous variables were reported as % and mean value, and compared between groups with the Chi2 Test and ANOVA Test, respectively. Of the 933 patients included, 512 (55%) patients were transplanted with a clamshell access, 97 (10%) patients with a median sternotomy, and 324 (35%) patients with bilateral thoracotomies. Recipient age (55.4 vs. 51.9 vs. 52.7 years, p=0.007), body mass index (24.6 vs. 25.11 vs. 23.6 kg/m2, p=0.002), presence of diabetes (27% vs. 20% vs. 20%, p=0.040), and of pulmonary artery hypertension (73% vs. 81% vs. 59%, p<0.001) significantly differed between clamshell, sternotomy and thoracotomy groups. Intra-operative use of ECLS (53% vs. 99% vs. 31%, p<0.001), total ischemic time (414 vs. 335 vs. 489 min., p<0.001), and skin-to-skin time (423 vs. 366 vs. 372 min., p<0.001) significantly differed between groups. Post-transplant need for ECMO (18% vs. 10% vs. 11%, p=0.010), for tracheostomy (22% vs. 13% vs. 12%, p=0.002), and prevalence of pneumonia (13% vs. 35% vs. 24%, p<0.001) significantly differed between clamshell, sternotomy and thoracotomy groups. However, need for re-exploration due to bleeding (p=0.082), development of wound infections (p=0.818), length of stay (p=0.125) and in-hospital mortality (p=0.616) did not differ between groups. Unadjusted overall survival did not differ among groups (p=0.156), but 1-year mortality was worse in thoracotomy vs. sternotomy patients (adjusted OR=3.63, p=0.017). In the ECLS registry, sternotomy was associated with a shorter ischemic and skin-to-skin times, but a higher prevalence of pneumonia. Choice of surgical access did not adversely affect survival. [ABSTRACT FROM AUTHOR]

In lung transplantation, intraoperative extracorporeal membrane oxygenation (ECMO) allows transplanting high-risk patients, such as those with idiopathic pulmonary arterial hypertension (iPAH). However, early postoperative course is more complicated in patients with than without ECMO, with higher prevalence of severe primary graft dysfunction (PGD), a risk factor for chronic lung allograft dysfunction (CLAD). Aim of this retrospective study was to test the hypothesis if the worse early postoperative course in ECMO patients translates in a worse long-term graft function too. Our institutional lung database was searched for patients who were transplanted with intraoperative ECMO between January 2010 and September 2019. Perioperative and follow-up results were compared between patients transplanted with ECMO and without ECMO. Follow-up amounted to a median of 41 (19-71) months. During the study period, among the 1,189 lung-transplanted patients, 316 (27%) patients required ECMO and the remaining 848 (71%) patients did not. Twenty-four (2%) patients requiring intraoperative cardiopulmonary bypass (CPB) support were excluded. ECMO patients showed a higher pre-transplant surgical risk profile (iPAH, 23% vs 0%, p<0.001; lung fibrosis, 42% vs 28%, p<0.001; ECMO as bridge to transplantation, 25% vs 0, p<0.001; median LAS score 42.2 vs 34.8, p<0.001) and a more complicated early postoperative course (PGD grade 3 at 72 hours, 15% vs. 1%, p<0.001; in-hospital mortality, 11% vs 2%, p<0.001) than patients without ECMO. While graft survival was worse in patients with than in patients without ECMO, freedom from CLAD, biopsy-confirmed rejection and pulsed-steroid therapy did not differ between groups (figure 1). The worse graft survival in ECMO patients was driven by a higher in-hospital mortality, but graft function at follow-up did not differ in discharged patients transplanted with and without ECMO. [ABSTRACT FROM AUTHOR]

Purpose At our institution, since 2012, we have applied a protocol using perioperative veno-arterial extracorporeal membrane oxygenation (v-a ECMO) support in all patients with acute massive pulmonary embolism, in order to reduce the impact of hemodynamic instability. In this study, we present the results of perioperative ECMO-therapy in these high-risk surgical patients. Methods We retrospectively reviewed all patients who underwent embolectomy due to massive acute pulmonary embolism at our institution between 11/2012 and 10/2018. In these patients, v-a ECMO was implanted percutaneously in the femoral vessels before the beginning of the anaesthesia, if it had not already been implanted before. At the end of operation, cardiopulmonary bypass support was switched again to v-a ECMO support, which was continued perioperatively at the intensive care unit. Results During the study period, 20 patients (median age 64 years, 75% male patients, 10% cardiac redos) underwent pulmonary embolectomy for acute massive embolism. Among these patients, preoperatively, 7 (35%) patients showed concomitant chronic thromboembolic pulmonary artery hypertension (CTEPH), 11 (55%) patients required mechanical ventilation, 14 (70%) patients required v-a ECMO support for cardiogenic shock and 11 (55%) patients had undergone thrombolysis. Median time under preoperative ECMO support amounted to 2 days. V-a ECMO was implanted before beginning of the anaesthesia in the remaining 6 (30%) patients. Intraoperatively, cardiopulmonary and cross clamp times amounted to a median of 127 and 53 minutes, respectively. Seven (35%) patients underwent pulmonary endarterectomy for concomitant CTEPH. V-a ECMO was continued after the end of the operation in all patients and weaned successfully after a median of 5 days. Twelve (60%) patients were extubated before ECMO weaning. Six (30%) patients required prolonged ventilation and underwent tracheostomy. Three (15%) patients required rethoracotomy for bleeding and 5 (25%) patients required new dialysis treatment. One (5%) patient showed lung reperfusion injury. Two (10%) patients died in-hospital of sepsis. Conclusion Ourv-a ECMO based protocol for massive acute pulmonary embolectomy led to stabilization of preoperative compromised haemodynamic. Postoperative ECMO provided good postoperative results in high risk patients. [ABSTRACT FROM AUTHOR]

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<0.01) and a dilated and hypertrophied right ventricle (OR 2.6 95%CI 1.4-4.9, p<0.01) were identified as risk factors for ECMO support. A PVR value exceeding 575 dynes-sec-cm−5 predicted the need of ECMO with a sensitivity of 76%. Decreased cardiac index is a risk factor for ECMO support, but did not reach significance in our study (OR 0.7; 95%CI 0.47-1.03, p=0.06). Higher recipient body surface area (BSA, OR 0.3; 95%CI 0.1-0.7, p=0.01) was a protective factor against intraoperative ECMO (H-L statistic, p=0.91). Postoperatively, more group A than B patients showed primary graft dysfunction grade 2 or 3 at 72 hours (25% vs. 14%, p=0.01), required re-thoracotomy for bleeding (7% vs. 1%, p<0.01) and temporary dialysis (16% vs. 5%, p<0.01). Survival at 5 years did not significantly differ in both groups (62% vs. 58%, p=0.63). 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. [ABSTRACT FROM AUTHOR]