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Correspondence |

Lung Transplant Candidates on Extracorporeal Support FREE TO VIEW

Franziska C. Trudzinski, MD; Heinrike Wilkens, MD; Onnen Moerer, MD; Ralf M. Muellenbach, MD; Frank Langer, MD; Charles W. Hoopes, MD; Joseph B. Zwischenberger, MD; Philipp M. Lepper, MD
Author and Funding Information

Editor’s Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: F. C. T., R. M. M., and P. M. L. have received fees for lectures, travel support, and/or consultations from Maquet Critical Care. H. W. has received fees for lectures, travel support, and/or consultations from Actelion, Bayer, Biotest, Boehringer, GSK, Pfizer, and Roche and a grant from Actelion. Within the past 36 months, O. M. gave lectures on mechanical ventilation and hemodynamic monitoring at regional workshops and industry-sponsored sessions on national congresses and received speaker's honoraria from Pulsion Medical, HillRom, and Maquet Critical Care. J. B. Z. receives grant funds from the NIH through a UK subcontract and from Xenios Austria Gmbh, serves as a consultant and Chair of the Cardiac Advisory Board of CytoSorb, receives royalties from Avalon-Maquet for the licensed patent of the double-lumen cannula that he coinvented, holds five other patents and two patents pending for medical devices he has coinvented, is a partner in WZ Biotech, and is a long-standing proponent for ECMO and the development of new technologies and medical devices. None declared (F. L., C. W. H.).

aDepartment of Internal Medicine V—Pneumology, Allergology, and Critical Care Medicine, University Hospital of Saarland, Homburg/Saar, Germany

bDepartment of Thoracic and Cardiovascular Surgery, University Hospital of Saarland, Homburg/Saar, Germany

cDepartment of Anaesthesiology, University Hospital of Göttingen, Göttingen, Germany

dDepartment of Anaesthesiology and Critical Care, Campus Kassel of the University of Southampton, Kassel, Germany

eDepartment of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL

fDepartment of Surgery, University of Kentucky, Lexington, KY

CORRESPONDENCE TO: Philipp M. Lepper, MD, Department of Internal Medicine V, University Hospital of Saarland, Kirrberger Strasse 100, Homburg 66421


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


Chest. 2017;151(5):1177-1178. doi:10.1016/j.chest.2016.12.035
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We read with great interest the review about ICU care before and after lung transplantation (LTx) by Fuehner et al. The authors suggest irreversible extrapulmonary organ failure, septic shock, severe arterial occlusive disease, and not being previously listed as specific contraindications for bridge to transplantation (BTT) with extracorporeal life support (ECLS).

We agree that patients in the ICU present challenges regarding LTx eligibility. Many factors impact the quality of the donor and the recipient as well as the overall lack of suitable donor organs. Furthermore, high-urgency transplantation or patients with multiple comorbidities may yield a higher risk of failure. Many patients in the ICU, especially those without previous LTx evaluation, will be disqualified under these circumstances.

However, transplantation is a social commitment toward all motivated and suitable candidates, regardless of whether they have been previously listed or not. A published list of specific contraindications proclaimed by a single group may prevent physicians from offering life-saving mechanical ventilation (MV) or ECLS, or both, to patients who may benefit. Early intervention with MV or ECLS, or both, is a growing trend among active lung transplantation centers. A 2015 Society for Cardiac Angiography/American College of Cardiology/Heart Failure Society of America/Society of Thoracic Surgeons Clinical Expert Consensus Statement on the Use of Percutaneous Mechanical Circulatory Support Devices recommended ambulatory ECMO (ECLS) as a strategy for BTT. Although not published, the American Society for Thoracic Surgery has also recommended the use of ambulatory ECMO for BTT. Likewise, in the Conventional Ventilatory Support vs Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure (CESAR) trial, survival from treatment of ARDS was superior when treated at a major center with ECMO expertise, and those placed on ECMO also showed improved outcomes.

Inclusion and exclusion criteria for ECLS as BTT are still evolving. Clearly, one bridging strategy using ECLS will not fit all entities. Ambulatory ECLS may allow better muscle conditioning, improve pulmonary function, and avoid frailty. Further, historical ECLS strategies will yield different results in different underlying conditions. Apart from improved ECLS technology, center volume, and ECLS experience, underlying disease and surgical skills influence outcome. Recently, Dellgren et al reported long-term outcomes in 20 patients acutely bridged to LTx with ECMO. Most patients (14 of 20) were not listed before the decision for ECMO was made. Although four patients died while receiving ECMO, the success for bridging was 80%. Seventeen patients were supported with MV when the decision for ECMO was made. Three patients had severe hemodynamic compromise, and 1-year survival was 62%, being in the range of previous reports citing 57% to 93% survival.,

The criteria by Fuehner et al reflect only a single-center opinion. One must use caution when interpreting single-institution recommendations. This center currently does not use ambulatory or disease-specific criteria for ECLS as a BTT. We recommend that LTx eligibility for a candidate with pulmonary failure who is in the ICU include evaluation by an ECLS-experienced lung transplantation center. For this evaluation, it might be on top necessary to judge at the bedside, if the patient is to reject.

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]
 
Rihal C.S. .Naidu S.S. .Givertz M.M. .et al 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. J Cardiac Fail. 2015;21:499-518 [PubMed]journal. [CrossRef]
 
Peek G.J. .Mugford M. .Tiruvoipati R. . CESAR trial collaborationet al Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomized controlled trial. Lancet. 2009;17:1351-1363 [PubMed]journal
 
Trudzinski F.C. .Kaestner F. .Schafers H.J. .et al Outcome of patients with interstitial lung disease treated with extracorporeal membrane oxygenation for acute respiratory failure. Am J Respir Crit Care Med. 2016;193:527-533 [PubMed]journal. [CrossRef] [PubMed]
 
Diaz-Guzman E. .Hoopes C.W. .Zwischenberger J.B. . The evolution of extracorporeal life support as a bridge to lung transplantation. ASAIO J. 2013;59:3-10 [PubMed]journal. [CrossRef] [PubMed]
 
Dellgren G. .Riise G.C. .Sward K. .et al Extracorporeal membrane oxygenation as a bridge to lung transplantation: a long-term study. Eur J Cardiothorac Surg. 2015;47:95-100 [PubMed]journal. [CrossRef] [PubMed]
 
Hoopes C.W. .Kukreja J. .Golden J. .Davenport D.L. .Diaz-Guzman E. .Zwischenberger J.B. . Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Thorac Cardiovasc Surg. 2013;145:862-867 [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]
 
Rihal C.S. .Naidu S.S. .Givertz M.M. .et al 2015 SCAI/ACC/HFSA/STS Clinical Expert Consensus Statement on the use of percutaneous mechanical circulatory support devices in cardiovascular care (Endorsed by the American Heart Association, the Cardiological Society of India, and Sociedad Latino Americana de Cardiologia Intervencion; Affirmation of value by the Canadian Association of Interventional Cardiology-Association Canadienne de Cardiologie d'intervention. J Cardiac Fail. 2015;21:499-518 [PubMed]journal. [CrossRef]
 
Peek G.J. .Mugford M. .Tiruvoipati R. . CESAR trial collaborationet al Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomized controlled trial. Lancet. 2009;17:1351-1363 [PubMed]journal
 
Trudzinski F.C. .Kaestner F. .Schafers H.J. .et al Outcome of patients with interstitial lung disease treated with extracorporeal membrane oxygenation for acute respiratory failure. Am J Respir Crit Care Med. 2016;193:527-533 [PubMed]journal. [CrossRef] [PubMed]
 
Diaz-Guzman E. .Hoopes C.W. .Zwischenberger J.B. . The evolution of extracorporeal life support as a bridge to lung transplantation. ASAIO J. 2013;59:3-10 [PubMed]journal. [CrossRef] [PubMed]
 
Dellgren G. .Riise G.C. .Sward K. .et al Extracorporeal membrane oxygenation as a bridge to lung transplantation: a long-term study. Eur J Cardiothorac Surg. 2015;47:95-100 [PubMed]journal. [CrossRef] [PubMed]
 
Hoopes C.W. .Kukreja J. .Golden J. .Davenport D.L. .Diaz-Guzman E. .Zwischenberger J.B. . Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Thorac Cardiovasc Surg. 2013;145:862-867 [PubMed]journal. [CrossRef] [PubMed]
 
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