Elective Extracorporeal Circulatory Support in Lung Transplantation for Pulmonary Fibrosis: A 3-year Experience after Protocol Adjustment

Background: In this study, we present our 3-year experience with elective intraoperative extracorporeal membrane oxygenation (ECMO) in patients with pulmonary fibrosis undergoing lung transplantation (LTx). The ECMO protocol in these patients was modified in 2020 based on previous studies.

Methods: Patients with pulmonary fibrosis as transplant indication undergoing LTx between January 2012 and December 2023 were included. We sub-divided patients into the period before and after protocol modification. Outcomes were compared between elective, not elective, and no intraoperative ECMO support in both study periods.

Results: Since protocol modification in 2020, 119 patients with pulmonary fibrosis underwent LTx (elective intraoperative ECMO n = 73 [61%], not elective ECMO n = 11 [9%], no ECMO support n = 35 [30%]). Before protocol modification, 60/308 (19%) patients with pulmonary fibrosis required elective ECMO, 31/308 (10%) patients not elective ECMO, and 217/308 (70%) were transplanted without ECMO support. The direct comparison of sub-groups after protocol modifications showed pre-transplant increased mean pulmonary arterial pressure (PAPmean: median 30 versus 22, p < 0.001) as well as pulmonary vascular resistance (PVR: median 3.9 versus 2.5, p < 0.001) in elective ECMO patients compared with patients without ECMO support. In Receiver Operating Curve, cut-off values in PAPmean >26 mmHg and PVR >3.07WU were accompanied by the suggestion of intraoperative ECMO support. In 11 (9%) patients, the preoperative parameters did not initiate elective ECMO, though during surgery not elective ECMO implantation was necessary. In these patients, no differences in donor organ quality assessed by donor age, smoking history, ventilation time, and donor–recipient size mismatch as well as recipient characteristics were present compared with patients without intraoperative ECMO. Comparing the two study periods, a clear improvement in Primary Graft Dysfunction 72 hours post-transplant between elective (4.1% vs. 15.5%, p = 0.025), not elective (0% vs. 36.7%, p = 0.025), and no ECMO support (2.9% vs. 12%, p = 0.105) was achieved. Further, the 1-year graft survival in elective (94.3% vs. 81.7%), not elective (90.9% vs. 71%), and no ECMO patients (91.4% vs. 90.7%) improved without statistical significance.

Conclusion: In selected patients with pulmonary fibrosis, elective ECMO support during transplantation is reasonable due to increased PAP and PVR. Still, some patients needing ECMO support remain undetected in our modified protocol.

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Artikel online veröffentlicht:
11. Februar 2025