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Stefania Crotti, MD; Giorgio A. Iotti, MD; Alfredo Lissoni, MD; Luciano Gattinoni, MD
Author and Funding Information

From the Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore; Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan (Drs Crotti and Lissoni); Anestesia e Rianimazione 2, Fondazione IRCCS Policlinico S. Matteo (Dr Iotti); and the Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche, Università degli Studi (Prof Gattinoni).

Correspondence to: Stefania Crotti, MD, Department of Anesthesia and Intensive Care, Intensive Care Unit “E.Vecla,” Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, 20121, Italy; e-mail: stefania.crotti@policlinico.mi.it


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):185. doi:10.1378/chest.13-2107
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To the Editor:

We thank Dr Venado and colleagues for their interest in our article.1 In a series of 25 patients already listed for lung transplantation, we started extracorporeal membrane oxygenation (ECMO) bridging after acute severe deterioration, with a 76% 1-year survival in 17 patients who underwent transplant. We observed a striking effect of ECMO duration on overall mortality as well as on posttransplant mortality and morbidity.

Dr Venado and colleagues, underlining that patients undergoing transplant after ECMO bridging have a good outcome,1-3 express some skepticism about the relationship between ECMO duration and unfavorable results. When considering all patients admitted to an ECMO bridge program and pooling together bridges of different duration, a good 1-year survival rate1-3 does not imply that ECMO duration is irrelevant. Indeed, the effects of bridge duration cannot be inferred from the data reported in the Toyoda et al2 case series. In the report of Hoopes et al,3 we observe a trend toward lower 1-year survival in long-term ECMO, with eight of 10 survivors in the > 14-days group, compared with 21 of 21 in the ≤ 14-days group. More specifically, in our study, mortality increased with each additional day on ECMO, not only during the ECMO bridge but also after transplantation, when ECMO bridge had been > 2 weeks.

Correctly, Dr Venado and colleagues point out that outcome depends also on the experience in prolonged ECMO as well as on the use of marginal-quality organs. Our center in Milano has used ECMO in ARDS for > 30 years4 and has successfully treated many patients with ARDS with prolonged ECMO. As for the role of using marginal donors, this is discussed and excluded in our article (see e-Appendix 2 in our article).1

We speculate whether the effects of ECMO bridge duration depend just on the side effects of ECMO or on the severe pathologic condition of the patients. In our series of critically ill patients, ECMO was just a makeup for blood gases and hemodynamics, and only transplantation could resolve a patient’s critically ill status. In this context, the shorter the waiting time, the lower the risk associated with being critically ill. ECMO bridge time effect may be different for patients amenable to a substantial improvement of their critically ill status (to the extreme of bridge to recovery). Considering the difficulties in predicting subsequent patient evolution at the beginning of the bridge, we maintain that prioritizing organ allocation to ECMO-bridged patients will benefit the overall outcome of this population.

Acknowledgments

Other contributions: The work was performed at the Ospedale Ca’ Granda of Milan and Policlinico San Matteo of Pavia, Italy.

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]
 
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]
 
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]
 
Gattinoni L, Pesenti A, Mascheroni D, et al. Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA. 1986;256(7):881-886. [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]
 
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]
 
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]
 
Gattinoni L, Pesenti A, Mascheroni D, et al. Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA. 1986;256(7):881-886. [CrossRef] [PubMed]
 
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