Extracorporeal Membrane Oxygenation Following Lung

Transplantation in Adult

ISKANDER AL-GITHMI, M.D., FRCSC, FRCSC (Ts & CDs), FCCP.

Assistant Professor of Surgery

Division of Cardiothoracic Surgery

King Abdulaziz University

Extracorporeal Membrane Oxygenation Following Lung

TransplantationLung transplantation is well established procedure.

Is the only acceptable option in selected

patients with end-stage pulmonary disease refractory to max. medical treatment.

According to ISHLT and international registry 23,716 lung transplantation were performed worldwide as of 2006.

Overall mortality following lung transplant is still notable, with one year survival is 80%.

How many transplant recipients require ECMO?

Primary graft failure

Bridge for re-do lung transplant.

Answer

Handful- Very small series spread over the last 3 decades.

1975-1st case of ECMO used as a bridge to lung transplant was performed

1991 Hannover group published the first report of long-term survival after using ECMO as bridge to re-do lung transplant

1992- Hannover group reported the first long term (12 months) survivor after using ECMO as bridge to primary lung transplant.

Indications

Severe Allograft Failure

Bridge to bridge

Bridge to transplantation

Primary Allograft Failure

Criteria/ ISHLT:Diffuse alveolar opacities exclusively involving allograft, developing within 72 hours after lung transplantation

PaO2 / FIO2 ratio < 200 beyond 48 hours post transplantNo other cause of graft failure identified such as rejection, infection or pulmonary venous obstruction

Primary Graft Failure

10-30% of transplant recipients develop primary graft failure

ECMO may provide lifesaving temporary support

ECMO long-term efficacy is controversial

ECMO goals:Maintain adequate oxygenation and ventilationDecrease pulmonary artery pressure, to decrease trans-capillary gradients in pulmonary vasculatureReduce rate and tidal volume of mechanical ventilation, to limit ventilator-induce lung injury

Selective Use of ECMO After Lung Transplant

Meyers et al –Washington University conducted a retrospective study on:

444 adult lung transplant -(1988-1998)

12 patients (2.7%) require ECMO support for severe graft failure

Table 1. General Characteristics of Patients Treated with ECMO

Patient Sex Diagnosis Transplant

Type

Ischemic Time,

First Graft (min)

Ischemic Time,

2nd Graft (min)

CPB Time

(min)

1 F PH Single 480 NA 211

2 F Cf Bilateral 300 523 315

3 F PH Single 275 NA 297

4 F CF Bilateral 330 480 104

5 F PH Bilateral 265 310 267

6 F PH Bilateral 270 300 280

7 F Sarcoidosis Bilateral 198 310 99

8 F PH Bilateral 290 315 269

9 F Bronchiectasis Bilateral 257 511 204

10 M IPF Bilateral 307 363 None

11 F CF Bilateral 330 330 197

12 F COPD Bilateral 314 464 None

PHPH, , Pulmonary Hypertension; Pulmonary Hypertension; NANA, Not Applicable; , Not Applicable; CFCF, Cystic Fibrosis; , Cystic Fibrosis; IPFIPF, Idiopathic Pulmonary Fibrosis; , Idiopathic Pulmonary Fibrosis; COPDCOPD, Chronic Obstructive Pulmonary Disease, Chronic Obstructive Pulmonary Disease

Table II. Response of Physiologic Profile to ECMO Support

Pre-ECMO 4 Hours of ECMO

P

Value

pH 7.29 ± 0.11 7.39 ± 0.07 .005

P02 (mm Hg) 52.2 ± 8.4 230 ± 78 .001

PC02 (mm Hg) 46.3 ± 11.8 33.9 ± 3.6 .001

F102 (%) 100 ± 0 59.2 ± 21.9 .001

PIP (cm H2O) 63.3 ± 14.7 37.4 ± 4.0 .001

PAP (mm Hg) 39.2 ± 8.9 18.5 ± 6.8 .001

F102, Fraction of Inspired Oxygen; PIP, Peak Inspiratory Pressure; PAP, Pulmonary Arterial Pressure

Table IV. Result of ECMO on Lung Recovery and Patient Survival

Patient ECMO Start ECMO Days Weaned Outcome Comment

1

2

3

4

5

6

7

8

9

10

11

12

0

1

0

0

0

1

2

8

1

1

0

0

3

1

4

3

4

10

10

1

1

8

4

1

Yes

Yes

Yes

Yes

Yes

No

No

No

Yes

No

Yes

Yes

Lived

Lived

Died

Lived

Lived

Died

Died

Died

Lived

Died

Lived

Lived

Weaned but died 4 weeks later, brain death

Failure to improve; support withdrawn Massive hemorrhage Brain death Successful retransplant Failed retransplant

ECMO start, Days elapsed between lung transplant and ECMO cannulation; ECMO days, length of ECMO support; weaned, removed from ECMO circuit before death.

Conclusion: This data do not offer adequate information to assess ECMO risk factors.

Clinical Risks Factors Associated with Graft Failure After Lung

TransplantChristie et al conducted cohort study on 255 consecutive lung transplants between 1991-2000

Overall incidence of graft failure after transplant was 11.8%

Multivariate analysis shows the risk factors associated with the development of graft failure were: primary pulmonary HTN, female gender, donor age < 21 yrs > 45 yrs

Long-term Survival of Transplant recipients After

ECMO use for PGF Bermudez et al conducted a study on:

763 lung or heart-lung transplant

58 patients (7.6%) required early [0-7 days after transplant] ECMO support for PGF

Mean duration of support was 5.5 days

Mean follow-up was 4.5 years

Results

Results

30 days survival was 80%

1 year survival was 39%

5 years survival was 33%

Conclusion: ECMO group survival is inferior to non ECMO group

Conclusions:Extracorporeal membrane oxygenation can provide acceptable support for PGF after lung transplantation.Overall benefits of ECMO in lung transplantation for PGF is still being defined. No registry exist that specifically collect ECMO data in the field of lung transplantation.

Thank You