PURPOSE: As we push the limits to offer lung transplantation to as many patients as possible by extending the recipient and donor selection criteria, primary graft failure becomes inevitable. How to manage primary graft failure can determine successful vs. unsuccessful outcomes. Controversy exists whether veno-venous vs. veno-arterial extracorporeal membrane oxygenation (ECMO) is superior in primary graft failure.
METHODS: A retrospective analysis was conducted using our prospectively collected database. From 1/1/2003 to 3/1/2011, 792 lung transplants, excluding combined heart-lung transplants, were performed at our center. Thirty nine (4.9%) lung transplants developed severe primary graft failure requiring ECMO. Veno-venous ECMO was used for 26 cases whereas veno-arterial ECMO was used for 13. Veno-venous ECMO was the first choice for lung failure alone whereas veno-arterial ECMO was used only when the patient had both cardiac and pulmonary failure.
RESULTS: ECMO group (n=39) had significantly (p<0.05) higher lung allocation score (56+/-21) vs. 44+/- 15 with no ECMO (n=734). The ischemic time and cardiopulmonary bypass time were significantly longer in ECMO group. Thirty-day, 1 and 3 year survival was significantly (p<0.05) worse with ECMO (79%, 44% and 41%) vs. no ECMO (97%, 84% and 69%). Within the ECMO group, 30-day, and 1-year survival was significantly (p<0.05) better with veno-venous (88%, and 67%) vs. veno-arterial (62%, and 21%) ECMO.
CONCLUSIONS: With our strategy being veno-venous ECMO for lung failure alone and veno-arterial ECMO for simultaneous lung and heart failure, veno-venous ECMO provides good outcomes (1-year survival rate being 67%) despite life-threatening situation with severe primary graft failure following lung transplantation. Randomised study comparing veno-venous vs. veno-arterial ECMO is warranted.
CLINICAL IMPLICATIONS: Clinicians will learn that veno-venous ECMO is safe and efficacious to save patients' life in the setting of severe primary graft failure following lung transplantation.
DISCLOSURE: The following authors have nothing to disclose: Yoshiya Toyoda, Jay Bhama, Norihisa Shigemura, Pramod Bonde, Aditya Bansal, Maria Crespo, Joseph Pilewski, Christian Bermudez
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