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Thomas Fuehner, MD; Christian Kuehn, MD; Tobias Welte, MD; Jens Gottlieb, MD
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FINANCIAL/NONFINANCIAL DISCLOSURES: See earlier cited article for author conflicts of interest.

aDepartment of Respiratory Medicine, Hannover Medical School, Hannover, Germany

bDepartment of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany

CORRESPONDENCE TO: Thomas Fuehner, MD, Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(5):1178-1179. doi:10.1016/j.chest.2017.02.026
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We thank Dr Trudzinski and colleagues for their comments regarding extracorporeal life support (ECLS) in lung transplantation (LTx) and their interest in our review recently published in CHEST (August 2016). Contrasting the opinion that ECLS need alone will strengthen the argument for transplantation, we strongly urge clear appraisal of the facts.

As conceded in their reply, 1-year survival rates for ICU candidates are poor. The figures quoted corroborate data from 134 ICU patients undergoing transplantation in Germany between 2011 and 2014, of whom just 56% were alive after 1 year. These figures are inferior to both published US data, where rates from ECLS and/or mechanical ventilation were 70%, and our institutional rates from ECLS. It is notable that the proportion of supported candidates in this period was double that observed in the United States (13% vs 6.4%), arguably reflecting inappropriate ECLS candidate selection in some centers. Intriguingly, 1-year overall survival post-LTx at our colleagues’ center was similar to these rates, significantly lower than what we would be accustomed to (https://www.dso.de; 91% vs. 76% for 2013).

While agreeing wholeheartedly with the social commitment toward all suitable candidates, we are perturbed by its interpretation, however. First, the expressed interpretation seems to selectively ignore all suitable candidates not currently requiring an ICU stay. Second, suitability can only be ascertained through complete evaluation, which in our experience is essentially impossible in the ICU setting. This assessment refers not only to diagnostic tests but also providing the candidate with a balanced perspective of LTx. Third, it gives no consideration to ethical commitment toward the donor and their families who graciously donate scarce organs and abdicate clinical responsibility to provide best utility.

The role of ECLS in the ICU is valid and does not warrant further explanation here. Use of bridging to transplant is by all means valid and, as the authors point out, requires bedside assessment of an experienced transplant physician in highly selected candidates. In most circumstances, the goal is avoidance of futile transplantation attempts rather than allowing technology-driven procrastination to creep into clinical decision-making.

As the US data confirm, high-volume centers are best placed for such decision-making, being associated with a 20% improvement in absolute survival rates. It is therefore difficult for Dr Trudzinski and colleagues to justify their criticisms of our experience in candidate selection. According to national registries, our center has performed 2.5-fold more LTx procedures (n = 1,010) in the last 10 years than the respective centers of the corresponding authors combined (www.dso.de, https://optn.transplant.hrsa.gov/data/view-data-reports/center-data/). In addition, we have published a series of pioneering articles regarding mechanical support in LTx, including novel bridging strategies and the largest single-center study on LTx candidates on mechanical support.

The published recommendations are compatible with the consensus from the International Society of Heart and Lung Transplantation. This document is recommended to the authors, giving more balance than personal opinion of critical care physicians in a low-volume center. Should the authors wish to better understand their social and ethical commitments toward future candidates, we encourage visiting a high-volume program.

References

Fuehner T. .Kuehn C. .Welte T. .Gottlieb J. . ICU care before and after lung transplantation. Chest. 2016;150:442-450 [PubMed]journal. [CrossRef] [PubMed]
 
Gottlieb J. .Smits J. .Schramm R. .et al Lung transplantation in Germany after introduction of the lung allocation score—a retrospective analysis. Dtsch Arztebl Int. 2017;114:179-185 [PubMed]journal. [PubMed]
 
Schechter M.A. .Ganapathi A.M. .Englum B.R. .et al Spontaneously breathing extracorporeal membrane oxygenation support provides the optimal bridge to lung transplantation. Transplantation. 2016;100:2699-2704 [PubMed]journal. [CrossRef] [PubMed]
 
Fuehner T. .Kuehn C. .Hadem J. .et al Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation. Am J Respir Crit Care Med. 2012;185:763-768 [PubMed]journal. [CrossRef] [PubMed]
 
Hayanga J.W. .Lira A. .Aboagye J.K. .Hayanga H.K. .D'Cunha J. . Extracorporeal membrane oxygenation as a bridge to lung transplantation: what lessons might we learn from volume and expertise? Interact Cardiovasc Thorac Surg. 2016;22:406-410 [PubMed]journal. [CrossRef] [PubMed]
 
Gottlieb J. .Warnecke G. .Hadem J. .et al Outcome of critically ill lung transplant candidates on invasive respiratory support. Intensive Care Med. 2012;38:968-975 [PubMed]journal. [CrossRef] [PubMed]
 
Weill D. .Benden C. .Corris P.A. .et al A 1396 consensus document for the selection of lung transplant candidates: 2014—an update 1397 from the Pulmonary Transplantation Council of the International Society for Heart and 1398 Lung Transplantation. J Heart Lung Transplant. 2015;34:1-15 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Fuehner T. .Kuehn C. .Welte T. .Gottlieb J. . ICU care before and after lung transplantation. Chest. 2016;150:442-450 [PubMed]journal. [CrossRef] [PubMed]
 
Gottlieb J. .Smits J. .Schramm R. .et al Lung transplantation in Germany after introduction of the lung allocation score—a retrospective analysis. Dtsch Arztebl Int. 2017;114:179-185 [PubMed]journal. [PubMed]
 
Schechter M.A. .Ganapathi A.M. .Englum B.R. .et al Spontaneously breathing extracorporeal membrane oxygenation support provides the optimal bridge to lung transplantation. Transplantation. 2016;100:2699-2704 [PubMed]journal. [CrossRef] [PubMed]
 
Fuehner T. .Kuehn C. .Hadem J. .et al Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation. Am J Respir Crit Care Med. 2012;185:763-768 [PubMed]journal. [CrossRef] [PubMed]
 
Hayanga J.W. .Lira A. .Aboagye J.K. .Hayanga H.K. .D'Cunha J. . Extracorporeal membrane oxygenation as a bridge to lung transplantation: what lessons might we learn from volume and expertise? Interact Cardiovasc Thorac Surg. 2016;22:406-410 [PubMed]journal. [CrossRef] [PubMed]
 
Gottlieb J. .Warnecke G. .Hadem J. .et al Outcome of critically ill lung transplant candidates on invasive respiratory support. Intensive Care Med. 2012;38:968-975 [PubMed]journal. [CrossRef] [PubMed]
 
Weill D. .Benden C. .Corris P.A. .et al A 1396 consensus document for the selection of lung transplant candidates: 2014—an update 1397 from the Pulmonary Transplantation Council of the International Society for Heart and 1398 Lung Transplantation. J Heart Lung Transplant. 2015;34:1-15 [PubMed]journal. [CrossRef] [PubMed]
 
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