Twenty-year experience with extracorporeal life support as bridge to lung transplantation

Abstract

Objectives: Extracorporeal life support is increasingly used to bridge deteriorating candidates to lung transplantation. Nevertheless, only few systematic reports with a limited number of patients exist describing this practice and its changes over time. Methods:We retrospectively reviewed our institutional database and performed an era analysis to identify trends over time and risk factors for mortality. After applying propensity score matching, outcomes of bridged patients were compared with those of standard lung transplantation recipients.Results: Extracorporeal life support was used in 120 patients as an intention to bridge to lung transplantation. Eleven patients (9.2%) were bridged between 1998 and 2004, 39 patients (32.5%) were bridged between 2005 and 2010, and 70 patients were bridged (58.3%) between 2010 and 2017. In the first era, the main bridging modality was venoarterial-extracorporeal membrane oxygenation (n ¼ 10, 90.9%), whereas venovenous devices were primarily used in later eras (second era: n ¼ 18, 46.2%; third era: n ¼ 39, 55.8%). In the second and third eras, 9 patients (23.1%) and 24 patients (34.3%) could be bridged awake. Short-term outcome was poor in the first era, with only 36.4% of patients discharged alive but improved in later eras (53.8% and 77.1%; P ¼ .002). Extracorporeal life support-bridged patients showed an impaired short-term outcome compared with standard recipients. However, survival conditional on 90 days did not differ among the groups (P ¼ .178). In univariate and multivariate analyses, awake extracorporeal life support was protective for survival, whereas acute retransplantation was a risk factor for mortality.Conclusions: Over the past 2 decades, the role of extracorporeal life support bridging evolved from an acute rescue therapy to a semi-elective procedure. Stratified outcome analysis revealed that extracorporeal life support bridging yielded similar long-term survival compared with nonbridged patients.

Lung transplantation for COVID-19-associated acute respiratory distress syndrome in a PCR-positive patient

“…When turning the patient, repeated episodes of desaturation accompanied by bradycardia occurred and the ECMO cannulation had to be changed to a femorojugular configuration using larger cannulas (25F/21F). The changes to the cannulation resulted in stabilisation of the patient; however, ECMO run with regular physiotherapy while the patient was awake to avoid further deconditioning, as previously described in the setting of bridge to transplant, 6 , 7 was not feasible. 6 , 7 A complete investigation was initiated to consider the possibility of lung transplantation.…”

The Role of Awake Extracorporeal Membrane Oxygenation as Bridging Therapy for Lung Transplantation: A Retrospective Cohort Study

“…The proportion of males in the awake group was higher than in the non-awake group (78.8% vs. 46.9% p = 0.008). Awake ECMO patients had a signi cantly shorter median ICU stay and longer duration of VFDs compared to the non-awake ECMO group (ICU length of stay, 6 [4-9.5] vs. 16 [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22], p = 0.001; VFDs, 24 [11.0-25.0] vs. 0 [0.0-14.5], p = 0.001). Furthermore, more patients were able to gait after LTx in the awake group compared to the non-awake group (84.8% vs. 56.3%, p = 0.011).…”

“…It was considered a relative contraindication to lung transplantation in the 1970s and 1980s, due to poor perioperative outcomes and many complications [5,6]. However, as ECMO-related techniques and experience improved, literature on pre-transplant ECMO showed postoperative bene ts in high-risk candidates; accordingly, the proportion of patients receiving bridging ECMO is increasing [7][8][9][10][11].…”

Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications

“…Keeping a patient awake, breathing spontaneously and physically active by help of an awake ECMO strategy has been shown to be associated with a more favorable outcome with respect to successful lung transplant and long-term survival when compared to mechanical ventilation. [88][89][90][91] Large transplant centers have therefore increasingly adopted an awake ECMO strategy instead of mechanical ventilation. 92 The guidelines of the ELSO 93 have defined respiratory failure in need for intubation in a patient on lung transplant list as an independent indication for ECMO support.…”