Extracorporeal Membrane Oxygenation Following Lung Transplantation in Adult

1. 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

2. Extracorporeal Membrane Oxygenation Following Lung Transplantation • Lung transplantation is well established procedure. • Is the only acceptable option in selected patients with end-stage pulmonary disease refractory to max. medical treatment.

3. 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%.

4. How many transplant recipients require ECMO? • Primary graft failure • Bridge for re-do lung transplant.

5. 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

6. 1992- Hannover group reported the first long term (12 months) survivor after using ECMO as bridge to primary lung transplant.

7. Indications • Severe Allograft Failure • Bridge to bridge • Bridge to transplantation

8. 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 transplant • No other cause of graft failure identified such as rejection, infection or pulmonary venous obstruction

9. Primary Graft Failure • 10-30% of transplant recipients develop primary graft failure • ECMO may provide lifesaving temporary support • ECMO long-term efficacy is controversial

10. ECMO goals: • Maintain adequate oxygenation and ventilation • Decrease pulmonary artery pressure, to decrease trans-capillary gradients in pulmonary vasculature • Reduce rate and tidal volume of mechanical ventilation, to limit ventilator-induce lung injury

11. 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

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

16. Clinical Risks Factors Associated with Graft Failure After Lung Transplant • Christie 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

17. 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

18. Results

19. 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

20. Conclusions: • Extracorporealmembrane 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.

21. Thank You