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Correspondence |

Prolonged Extracorporeal Membrane Oxygenation Use as a Bridge to Lung TransplantationProlonged ECMO Prior to Lung Transplant: It Is Time for a National Registry FREE TO VIEW

Aida Venado, MD; Charles W. Hoopes, MD; Enrique Diaz-Guzman, MD
Author and Funding Information

From the Division of Pulmonary and Critical Care (Drs Venado and Diaz-Guzman), University of Alabama at Birmingham; and the Division of Cardiothoracic Surgery (Dr Hoopes), University of Kentucky.

Correspondence to: Enrique Diaz-Guzman, MD, University of Alabama at Birmingham, 619 19th St S, Jefferson Tower 1102, Birmingham, AL 35294-7410; e-mail: diaze@uab.edu


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(1):184-185. doi:10.1378/chest.13-1851
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To the Editor:

We read with great interest the article by Crotti et al1 in a recent issue of CHEST (April 2013). The authors present their experience with 17 patients who underwent extracorporeal membrane oxygenation (ECMO) prior to lung transplantation in two centers in Italy. In this series, patients who underwent transplantation “early” had better outcomes compared with those undergoing transplant “late,” defined as a waiting time on ECMO ≥ 14 days. Overall 1-year survival was 76% (100% in the early group vs 50% on the late group). The authors concluded that duration of ECMO is an important cofactor for mortality before and after lung transplantation.

The use of ECMO pretransplant has been controversial and considered by some as a contraindication to lung transplantation. ECMO was used in the past in cases of acute clinical deterioration as a life-saving therapy. By contrast, ECMO now can be used in patients to allow ambulation and rehabilitation and to prevent or reduce mechanical ventilation use.2,3 Recent series of patients undergoing transplant using ECMO in the United States have reported good midterm and long-term outcomes, with survival rates exceeding those undergoing transplant while on mechanical ventilation.3,4 In our recent report describing 31 patients bridged with ECMO, we observed a 1-year survival rate of 83% among those with prolonged ECMO use.3 Similarly, Toyoda et al4 reported 24 patients bridged with ECMO with a 1-year survival rate of 74%, although the authors report a higher incidence of primary graft dysfunction and posttransplant ECMO use compared with nonsupported patients.

Although we agree with the authors that prolonged ECMO use may increase the risk of mechanical complications pretransplant (ie, hemolysis, thrombosis, hemorrhage, and so forth), we believe that the current level of evidence is insufficient to conclude that prolonged ECMO (vs short ECMO use) results in worse outcomes after lung transplantation. Although we recognize the possible risks associated with ECMO, we hypothesize that many other factors may impact survival in this small and selected subgroup of patients. For example, center-specific lack of experience with prolong ECMO use and selection bias (prolonged ECMO use may reflect “sicker” patients and, therefore, higher frequency of marginal quality organ use) may negatively impact outcomes.

Can we translate the findings of this study to other practice settings? In the United States, the Lung Allocation System is based on survival probability and currently does not factor ECMO use, although these patients often have a high score.4 The uncertainty regarding ECMO benefits raises ethical concerns about organ waste and preferential use of marginal allografts or cadaveric lobar transplants. For example, Toyoda et al4 reported more frequent use of cadaveric lobar lung transplantation compared with “nonsupported” patients. We believe that this article should help stimulate a national dialogue to determine optimal use of ECMO as a bridge to lung transplant, consider its impact on organ allocation systems, and promote the creation of a national registry of ECMO use in respiratory failure (including those awaiting lung transplantation). Only then we will be able to answer some of the clinical and ethical questions surrounding ECMO use among these seriously ill patients.

References

Crotti S, Iotti GA, Lissoni A, et al. Organ allocation waiting time during extracorporeal bridge to lung transplant affects outcomes. Chest. 2013;144(3):1018-1025. [CrossRef] [PubMed]
 
Garcia JP, Iacono A, Kon ZN, Griffith BP. Ambulatory extracorporeal membrane oxygenation: a new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg. 2010;139(6):e137-e139. [CrossRef] [PubMed]
 
Hoopes CW, Kukreja J, Golden J, Davenport DL, Diaz-Guzman E, Zwischenberger JB. Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Thorac Cardiovasc Surg. 2013;145(3):862-867. [CrossRef] [PubMed]
 
Toyoda Y, Bhama JK, Shigemura N, et al. Efficacy of extracorporeal membrane oxygenation as a bridge to lung transplantation. J Thorac Cardiovasc Surg. 2013;145(4):1065-1070. [CrossRef] [PubMed]
 

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References

Crotti S, Iotti GA, Lissoni A, et al. Organ allocation waiting time during extracorporeal bridge to lung transplant affects outcomes. Chest. 2013;144(3):1018-1025. [CrossRef] [PubMed]
 
Garcia JP, Iacono A, Kon ZN, Griffith BP. Ambulatory extracorporeal membrane oxygenation: a new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg. 2010;139(6):e137-e139. [CrossRef] [PubMed]
 
Hoopes CW, Kukreja J, Golden J, Davenport DL, Diaz-Guzman E, Zwischenberger JB. Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Thorac Cardiovasc Surg. 2013;145(3):862-867. [CrossRef] [PubMed]
 
Toyoda Y, Bhama JK, Shigemura N, et al. Efficacy of extracorporeal membrane oxygenation as a bridge to lung transplantation. J Thorac Cardiovasc Surg. 2013;145(4):1065-1070. [CrossRef] [PubMed]
 
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