The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation

A Breath of Fresh Air - Lung Transplantation Has Come of Age

“…Owing to its risk of severe complications (i.e, ventilation-induced lung injuries, infection, and need for sedation leading to profound deconditioning), bridging with mechanical ventilation has been associated with increased mortality both pre-and post-transplantation, necessitating the need for more invasive support strategies [39,40]. Adoption of the LAS has effectively allocated organ transplantation to patients with the highest acuity, consequently driving the need for more invasive bridging to transplant (BTT) strategies in the form of mechanical circulatory support [41,42].…”

“…Extracorporeal membrane oxygenation can effectively provide respiratory support, cardiac support, or both based on cannulation sites. In patients with isolated pulmonary failure in the absence of hemodynamic instability or RV dysfunction, veno-venous ecmo (VV-ecmo) is preferred to venoarterial (VA-ecmo) [42,45,46]. However, it is not uncommon for worsening pulmonary vascular resistance and ensued right ventricular dysfunction to call for conversion to VA-ecmo, providing both cardiac and pulmonary support [42].…”

“…In patients with isolated pulmonary failure in the absence of hemodynamic instability or RV dysfunction, veno-venous ecmo (VV-ecmo) is preferred to venoarterial (VA-ecmo) [42,45,46]. However, it is not uncommon for worsening pulmonary vascular resistance and ensued right ventricular dysfunction to call for conversion to VA-ecmo, providing both cardiac and pulmonary support [42]. VV-ECMO cannot effectively address the high pulmonary vascular resistance or the right ventricular dysfunction commonly present in patients with fibrotic or vascular lung diseases [47].…”

“…VV-ECMO cannot effectively address the high pulmonary vascular resistance or the right ventricular dysfunction commonly present in patients with fibrotic or vascular lung diseases [47]. These patients are best supported with venoarterial (VA) ECMO [42,47]. The framework for mechanical circulatory support for BTT in the lung transplant candidate remains patient specific.…”

“…It is also useful in the event of global hypoxia or hypercapnia during single lung ventilation. For decades, cardiopulmonary bypass (CPB) has shown success in cardiac surgery, gradually becoming the method of choice for intraoperative support during lung transplantation [42,84]. Of recent years, the utility of CPB in lung transplantation has come into question as it has been associated with activation of the inflammatory cascade, as well as data supporting its role in acute lung injury and acute respiratory distress syndrome when used for other procedures [85].…”