Successful Bridging to Lung Transplantation in Patients with Need of ECMO and Invasive Mechanical Ventilation: Report of Mid-Term Outcomes

Purpose: Awake and spontaneously breathing during extracorporeal membrane oxygenation (ECMO) support in patients awaiting lung transplantation (LTx) is a novel bridging strategy. Here, we evaluated our experience of lung transplant recipients on ECMO without ventilatory support compared with invasive ventilated patients on ECMO prior to LTx with regard to mid -term outcomes.

Methods: Between May 2011 and June 2016, a total of 34 consecutive patients received ECMO support with or without mechanical ventilation (MV) as a bridge to bilateral LTx. Patients in the „awake ECMO“ group (n = 11) were non-invasive or not ventilated prior to transplantation. Twenty-three patients needed invasive MV.

Results: There were 23 male and 11 female patients with a median age of 44 years (range: 21–66 years). The underlying pulmonary diseases were cystic fibrosis (n = 14), idiopathic pulmonary fibrosis (n = 13), bronchiolitis obliterans organizing pneumonia (n = 1), pulmonary arterial hypertension (n = 1), α 1-antitrypsin deficiency (n = 1), idiopathic pneumonitis (n = 1), COPD (n = 1) and exogenous allergic alveolitis (n = 2). Seven patients died prior to LTx due to ECMO related complications (n = 1), right heart failure (n = 2), multiorgan failure (n = 2), massive pulmonary bleeding (n = 1) and retroperitoneal bleeding (n = 1). The median duration of ECMO support prior LTx was 15 days (range: 3–75 days) in the „awake ECMO“ group and 29 days (range: 4–78 days) in the invasive ventilated ECMO patients. Reasons for invasive MV were massive dyspnea (n = 17), pulmonary bleeding (n = 2), resuscitation (n = 1), abdominal compartment (n = 1) and two patients were already intubated upon ICU arrival. Kaplan-Meier survival rate after LTx of all ECMO patients was 70.4% at 6 months, 61.8% at 1 year and 51.4% at 3 years, respectively. There was no statistically significant difference in one-year survival between the two groups (p =0.58).

Conclusion: ECMO as a bridge-to-transplantation presents a valuable option for both intubated und non-intubated patients with end-stage pulmonary disease. Prolonged pre-transplant ECMO support does not preclude a successful mid-term outcome. Reluctance to place ECMO patients with need for invasive mechanical ventilation on a lung transplant waiting list appears not to be justified.