Extracorporeal life support in lung and heart–lung transplantation for pulmonary hypertension in adults

Abstract

After bilateral lung and heart-lung transplantation in adults with pulmonary hypertension, hemodynamic and oxygenation deficiencies are life-threatening complications that are increasingly managed with extracorporeal life support (ECLS). The primary aim of this retrospective study was to assess 30-day and 1-year survival rates in patients managed with vs without post-operative venoarterial ECLS in 2008-2013. The secondary endpoints were the occurrence rates of nosocomial infection, bleeding, and acute renal failure. Of the 93 patients with pulmonary hypertension who received heart-lung (n=29) or bilateral lung (n=64) transplants, 28 (30%) required ECLS a median of 0 [0-6] hours after surgery completion and for a median of 3.0 [2.0-8.5] days. Compared to ECLS patients, controls had higher survival at 30 days (95.0% vs 78.5%; P=.02) and 1 year (83% vs 64%; P=.005), fewer nosocomial infections (48% vs 79%; P=.0006), and fewer bleeding events (17% vs 43%; P=.008). The need for renal replacement therapy was not different between groups (11% vs 17%; P=.54). Venoarterial ECLS is effective in treating pulmonary graft dysfunction with hemodynamic failure after heart-lung or bilateral lung. However, ECLS use was associated with higher rates of infection and bleeding.

Intensive care, right ventricular support and lung transplantation in patients with pulmonary hypertension

“…To overcome this problem, several centres over many years have used combined heart and lung transplantation for patients with severe PH [66, 67]. Today, however, the post-operative prolongation of veno-arterial ECMO after transplantation effectively prevents primary graft dysfunction [48, 68]. Two different approaches have been described: 1) prolongation of ECMO with extubation first and continuation of ECMO support for 3–7 days [48] or 2) brief post-operative prolongation of ECMO in intubated patients until stabilisation of haemodynamics and normalisation of fluid balance followed by a few days of ventilation [49].…”

Acute decompensated pulmonary hypertension

“…For these reasons, the use of ECMO has been proposed in selected patients during a 48-72 h postoperative period until the end of the period of primary graft dysfunction (i.e. ischaemia-reperfusion lung injuries) [58,59]. Interestingly, a progressive reversibility of the myocardial remodelling leading to a recovery of a normal right ventricular function was observed after double lung transplantation, even in cases of end-stage right ventricular failure at time of listing.…”

Noteworthy Literature Published in 2016 for Thoracic Organ Transplantation Anesthesiologists

“…PGD, requirement for ECMO, and length of hospital stay more than 25 days in the hospital after LTX affected longterm functional recovery and survival. [65][66][67] LTX still has the lowest long-term survival rate, and long-term outcomes can be improved by preventing and treating early postoperative complications. 68 Because operative factors are predictive of early complications, anesthesiology and perioperative research play a significant role in improving LTX outcomes.…”