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    Lessons learned from extracorporeal membrane oxygenation as a bridge to lung transplantation

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        Abstract

        Extracorporeal membrane oxygenation (ECMO) has been used infrequently as a bridge to lung transplantation due to lack of consensus and data regarding the benefits of such a strategy. We present data from the United Network of Organ Sharing (UNOS) database on the outcomes of patients bridged to lung transplantation with ECMO. We used the UNOS database to analyze data between January 1, 2000 and December 31, 2011. During this time 14,263 lung transplants were performed, of which 143 (1.0%) were bridged using ECMO. Patients on ECMO as a bridge to lung transplantation were compared to those transplanted without prior ECMO support. Demographics, survival rates, complications, and rejection episodes were compared between the two groups. The 30-day, 6-month, 1-year, 3-year, and 5-year survival rates were 69%, 56%, 48%, 26%, and 11%, respectively, for the ECMO bridge group and 95%, 88%, 81%, 58%, and 38% respectively, for the control group ( p ≤ 0.01). The ECMO group incurred higher rate of postoperative complications, including airway dehiscence (4% vs. 1%, p ≤ 0.01), stroke (3% vs. 2%, p ≤ 0.01), infection (56% vs. 42%, p ≤ 0.01), and pulmonary embolism (10% vs. 0.6%, p ≤ 0.01). The length of hospital stay was longer for the ECMO group (41 vs. 25 days, p ≤ 0.01), and they were treated for rejection more often (49% vs. 36%, p = 0.02). The use of ECMO as a bridge to lung transplantation is associated with significantly worse survival and more frequent postoperative complications. Therefore, we advocate very careful patient selection and cautious use of ECMO.

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        Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation.

        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). To evaluate the outcomes of patients treated with the "awake ECMO" concept as bridge to transplantation. 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. 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). 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.
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          Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation.

          Acute clinical deterioration preceding death is a common observation in patients with advanced interstitial lung disease and secondary pulmonary hypertension. Patients with pulmonary arterial hypertension refractory to medical therapy are also at risk of sudden cardiac death (cor pulmonale). The treatment of these patients remains complex, and the findings from retrospective studies have suggested that intubation and mechanical ventilation are inappropriate given the universally poor outcomes. Extracorporeal support technologies have received limited attention because of the presumed inability to either recover cardiopulmonary function in the patient with end-stage disease or the presumed inability to proceed to definitive therapy with transplantation. A retrospective review was performed of 31 patients from 2 institutions placed on extracorporeal membrane oxygenation as a bridge to lung transplantation compared with similar patients without extracorporeal membrane oxygenation at the same institutions and comparison groups queried from the United Network for Organ Sharing database. We have transplanted 31 patients with refractory lung disease from mechanical artificial lung support. Of the 31 patients, 19 were ambulatory at transplantation. Pulmonary fibrosis (42%), cystic fibrosis (20%), and pulmonary hypertension (16%) were the most common diagnostic codes and acute cor pulmonale (48%) and hypoxia (39%) were the most common indications for device deployment. The average duration of extracorporeal membrane oxygenation support was 13.7 days (range, 2-53 days), and the mean survival of all patients bridged to pulmonary transplantation was 26 months (range, 54 days to 95 months). The 1-, 3-, and 5-year survival was 93%, 80%, and 66%, respectively. The duration of in-house postoperative transplant care ranged from 12 to 86 days (mean, 31 days). Patients requiring an extracorporeal membrane oxygenation bridge had comparable survival to that of the high acuity patients transplanted without extracorporeal membrane oxygenation support in the Scientific Registry of Transplant Recipients database but were at a survival disadvantage compared with the high-acuity patients (lung allocation score, >50) transplanted at the same center who did not require mechanical support (P < .001). 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. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
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            Efficacy of extracorporeal membrane oxygenation as a bridge to lung transplantation.

            Preoperative extracorporeal membrane oxygenation (ECMO) is a risk factor for poor outcome and currently considered a contraindication to lung transplantation. The lung allocation score system was introduced in May 2005 and prioritizes lung allocation to those with the greatest respiratory impairment. The purpose of this study is to determine whether ECMO as a bridge to lung transplantation is an acceptable option to support those in respiratory failure until donor lungs become available in the lung allocation score era. A retrospective review of 715 consecutive lung transplants performed between May 2005 and September 2011 was conducted using a prospectively collected institutional registry database. Twenty-four lung transplants (3.4%) were performed in the 31 patients with attempted pretransplant ECMO; 7 patients who received ECMO patients did not survive or were deemed unfit for transplantation. These patients were compared with a control group of 691 patients who did not receive pretransplant ECMO. The duration of pretransplant ECMO was 171 ± 242 hours (median, 91 hours). Venovenous ECMO was used for respiratory failure in 15 patients, whereas venoarterial ECMO was used for circulatory collapse due to pulmonary hypertension in 9 patients. Patients in the retransplant ECMO group were younger (46 ± 15 years vs 57 ± 14 years, P < .01) compared with the control group, with no difference in recipient gender (male/female: 10/14 vs 380/311), donor age (33 ± 14 years vs 36 ± 15 years), or donor gender (male/female: 10/14 vs 352/339). Emphysema was less common (1, 4% vs 260, 38%, P < .01), and cystic fibrosis (5, 21% vs 72, 10%, P = .09), redo lung transplant (3, 13% vs 28, 4%, P = .08), and bronchiectasis (2, 8% vs 6, 1%, P = .03) were more common in the pretransplant ECMO group. Patients in the pretransplant ECMO group had a significantly higher lung allocation score (87 ± 9 vs 44 ± 15, P < .01). All patients in the pretransplant ECMO group underwent double lung transplants on pump (cardiopulmonary bypass/ECMO), and single lung transplants were performed in 171 patients (25%) and pump was used in 243 patients (35%) in the control group. The cardiopulmonary bypass time was longer in the pretransplant ECMO group (277 ± 69 minutes vs 225 ± 89 minutes, P = .02), with no difference in ischemic time (343 ± 93 minutes vs 330 ± 98 minutes, P = .54). Cadaveric lobar lung transplants were performed because of the urgency to overcome size mismatch with an oversized donor more frequently in 25% (n = 6, no mortality with the longest follow-up at 6 years) of patients in the pretransplant ECMO group versus 0.3% (n = 2) of patients in the control group (P < .01). Post-transplant ECMO was used for primary graft dysfunction in 13 patients (54%) in the pretransplant ECMO group and 41 patients (6%) in the control group (P < .01). The median hospital stay was 46 days in the pretransplant ECMO group versus 27 days in the control group (P = .16). The actuarial survivals after lung transplants at 1, 3, 6, 12, and 24 months were 96%, 88%, 83%, 74%, and 74%, respectively, in the pretransplant ECMO group, and 97%, 94%, 90%, 83%, and 74%, respectively, in the control group (P = .787). Although the incidence of primary graft dysfunction requiring post-transplant ECMO is higher and the hospital stay is longer in patients receiving pretransplant ECMO, the graft survival is good (2-year survival, 74%). ECMO is efficacious as a bridge to lung transplantation with good post-lung transplant outcomes. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
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              Author and article information

              Affiliations
              [1 ]Bonde Artificial Heart Laboratory, Yale University School of Medicine, New Haven, CT, USA
              [2 ]Section of Cardiac Surgery, Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
              [3 ]Yale Center for Advanced Heart Failure, Mechanical Support, and Heart Transplantation, Yale University School of Medicine, New Haven, CT, USA
              Author notes
              [* ]Corresponding author's e-mail address: pramod.bonde@ 123456yale.edu

              Presented at the New England Surgical Society, 94th Annual Meeting, Hartford, CT, September 2013.

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              Journal
              SOR-MED
              ScienceOpen Research
              ScienceOpen
              2199-1006
              16 May 2014
              : 0 (ID: b24d23af-564f-402c-a9b3-2c132639ac4d )
              : 0
              : 1-8
              3753:XE
              10.14293/A2199-1006.01.SOR-MED.BG1R6.v1
              © 2014 Shumaster et al.

              This work has been published open access under Creative Commons Attribution License CC BY 4.0 , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com .

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