Early Institution of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation Improves Outcome

doi:10.1016/j.healun.2006.12.010

The Journal of Heart and Lung Transplantation

Volume 26, Issue 4, April 2007, Pages 331-338

https://doi.org/10.1016/j.healun.2006.12.010 Get rights and content

Background

Primary graft dysfunction (PGD) after lung transplantation (LTx) carries a significant mortality and clinical management is controversial. Extracorporeal membrane oxygenation (ECMO) has been used infrequently for recovery from acute lung injury (ALI) in this setting. We reviewed our experience with ECMO after primary LTx.

Methods

The present study is a retrospective analysis of all LTx patients between 1991 and 2004. Twenty-two patients sustained severe PGD with subsequent placement on ECMO. We analyzed indications and 30-day, 1-year and 3-year mortality. Complications and incidence of multiple-organ failure (MOF) were determined. Critical appraisal of the evidence available to date was performed.

Results

A total of 297 LTxs were performed during the study period, with 97.5%, 88.6% and 73.8% survival at 30 days, 1 year and 3 years, respectively. Twenty-two patients (7.9%) had severe allograft dysfunction leading to ECMO support. Twelve patients received single-lung (SLTx), 8 double-lung (BLTx), 1 single-lung/kidney (SLKTx) and 1 heart/lung (HLTx) transplantation. Thirty-day, 1-year and 3-year survival of LTx recipients with ECMO support post-operatively were 74.6%, 54% and 36%, respectively. MOF was the predominant cause of death (58.3%) in patients on ECMO support for PGD.

Conclusions

Our data suggest that, in addition to prolonged ventilation and pharmacologic support, ECMO should be considered as a bridge to recovery from PGD in lung transplantation. Early institution of ECMO may lead to diminished mortality in the setting of ALI despite the high incidence of MOF. Late institution of ECMO was associated with 100% mortality in this investigation.

Section snippets

Methods

A single-center analysis of 297 consecutive lung transplants (LTx) at the University of Wisconsin Hospital was performed. Retrospective analysis of UNOS data sheets and clinical case documentation was conducted for all primary single and bilateral LTxs. Patients with severe PGD, Grade 3 according to ISHLT guidelines,⁵ and subsequent ECMO were compared with an unaffected LTx cohort. For the evaluation of outcomes the patient cohort was divided into two groups: early institution of ECMO (<24

Patient Demographics

Twenty-two patients, 7.9%, had severe PGD (ISHLT Grade 3) requiring ECMO support due to refractory hypoxemia after lung transplantation (male-to-female ratio: 1.2:1). The primary pulmonary diagnoses of recipients leading to end-stage respiratory failure prior to transplantation are shown in Table 1, Table 2. Eleven of these patients were single-lung transplant (SLTx) recipients, 8 bilateral lung transplants (BLTx), 1 heart–lung transplant (HLTx), 1 patient was an SLTx who was placed on ECMO as

Discussion

The renewed interest in the application of ECMO for potentially reversible causes of respiratory failure has coincided with the refined technology and innovative ventilator strategies developed in the 1990s. The primary principle in this approach is to provide membrane oxygenation as a temporary replacement measure to allow for intrinsic mechanisms to repair the diffuse alveolar damage in a non-proliferative stage of acute lung injury. Although conceptually appealing, ECMO after lung

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Clinical lung and heart/lung transplantationEarly Institution of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation Improves Outcome

Background

Methods

Results

Conclusions

Section snippets

Methods

Patient Demographics

Discussion

J Heart Lung Transplant

Ann Thorac Surg

J Heart Lung Transplant

J Heart Lung Transplant

Chest

Ann Thorac Surg

Ann Thorac Surg

J Heart Lung Transplant

J Thorac Cardiovasc Surg

Clinical lung and heart/lung transplantation
Early Institution of Extracorporeal Membrane Oxygenation for Primary Graft Dysfunction After Lung Transplantation Improves Outcome