Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation

Abstract

These observations challenge current assumptions about the treatment of selected patients with end-stage lung disease and suggest that "salvage transplant" is both technically feasible and logistically viable. Widespread adoption of artificial lung technology in lung transplant will require the design of clinical trials that establish the most effective circumstances in which to use these technologies. A discussion of a clinical trial and reconsideration of current allocation policy is warranted.

Development of a new interfacility extracorporeal membrane oxygenation transport program for pediatric lung transplantation evaluation

“…Although it is impossible to refute this approach outright, more recent analyses of data sets with propensity score matching indicate that survival for children on ECMO at the time of transplant may not be significantly different than those who do not require ECMO. Moreover, the earlier literature characterized by poor outcomes predates the development of centrifugal pumps, miniaturized ECMO circuits, and general movement from venoarterial to VV ECMO configurations which are all potentially associated with fewer ECMO related complications (1,3,5,7). NCH offers ECMO as bridge to transplant for local patients, most of whom have cystic fibrosis, when critical illness occurs in previously-listed patients.…”

“…With the advent of pediatric transplant and the development of more reliable longerterm support devices (such as miniaturized ECMO circuits, centrifugal pumps, and ventricular assist devices) the prior resistance to use ECMO to support irreversible organ failure is increasingly being reconsidered. Use of ECMO to bridge patients to lung transplantation is increasingly being done at transplant centers (1)(2)(3)(4)(5)(6)(7). For these reasons, pediatric ECMO centers are finding themselves supporting patients with irreversible heart and/or lung failure for whom organ transplantation is a potentially life-saving intervention.…”

Extracorporeal membrane oxygenation for interstitial lung disease: what is on the other side of the bridge?

“…Patients requiring an ECMO bridge exhibited similar survival compared to patients transplanted without ECMO support. These results challenge current assumptions about the treatment of selected patients with end-stage lung disease and suggest that "salvage lung transplant" is both technically feasible and logistically viable (16). To achieve a complete and fair pre-LTx assessment, blood tests, radiological imaging and medicopsycho-social evaluation are mandatory.…”

A Step Up for Extracorporeal Membrane Oxygenation: Active Rehabilitation

“…9 Overall, outcomes following lung transplantation in patients bridged with extracorporeal life support, including ECMO, have been variable, depending on the patients, their indication for transplantation, and the configuration and duration of extracorporeal support. [10][11][12][13][14] The main benefits of awake ECMO are that the patient can eat, drink, communicate, and participate in active rehabilitation, which may be an important predictor of outcome, as reported in this issue by Rehder et al 15 In theory, early use of awake ECMO may result in more physically and physiologically stable patients, as compared to those receiving invasive mechanical ventilation at the time of lung transplantation, which may translate into improved post-transplant outcomes. Indeed, some investigators have cautioned that the use of awake ECMO may lower the risk profile of recipients, resulting in a lower priority on the waiting list.…”

“…Indeed, some investigators have cautioned that the use of awake ECMO may lower the risk profile of recipients, resulting in a lower priority on the waiting list. 12 In the largest case series to date, Fuehner and colleagues reported data from a retrospective single center analysis of 26 patients receiving awake ECMO, compared to a historical control group of 34 patients receiving conventional mechanical ventilation. 2 Survival at 6 months after lung transplant was 80% in the awake ECMO group, compared to 50% in the mechanical ventilation group.…”