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Eur J Cardiothorac Surg 2002;21:858-863
© 2002 Elsevier Science NL

Bilateral lung transplantation with intra- and postoperatively prolonged ECMO support in patients with pulmonary hypertension

^a Department of Cardiothoracic Surgery, Wahringer Gurtel 18-20, A-1090 Vienna, Austria
^b Department of Anesthesiology and Transplantation Intensive Care Unit, University of Vienna, Vienna, Austria

Received 2 October 2001; received in revised form 10 January 2002; accepted 16 January 2002.

* Corresponding author. Tel.: +43-1-40400-5644; fax: +43-1-40400-5642
e-mail: walter.klepetko{at}akh-wien.ac.at

Objective: Lung transplantation for pulmonary hypertension (PH) is usually performed on cardiopulmonary bypass, with the disadvantage of full systemic anticoagulation, uncontrolled allograft reperfusion and aggressive ventilation. These factors can be avoided with intra- and postoperatively prolonged extracorporeal membrane oxygenator (ECMO) support. Patients and methods: Between February 1999 and March 2001, 17 consecutive patients with PH (systolic pulmonary artery pressure >70 mmHg) of different etiologies underwent bilateral lung transplantation (BLTX). There were 11 females and six males in the age range from 7 to 50 years (mean age, 28.4±12.9 years). Six patients were preoperatively hospitalized, four in the intensive care unit (ICU), one was on ECMO for 3 weeks pretransplantation, and one was resuscitated and bridged with ECMO for 1 week until transplantation. Femoral venoarterial ECMO support with heparin-coated circuits was set up after induction of anesthesia and discontinued at the end of surgery (n=3) or extended for 12 h median into the postoperative period (n=14). Postoperative ventilation pressure was kept below 25 mmHg. Allograft function at 2 h after discontinuation of ECMO, outcome and adverse events were monitored in all patients. Mean follow up time was 18±11.4 months. Results: The perioperative mortality was 5.9% (n=1). Arterial oxygen pressure measured 2 h after weaning from ECMO, and under standard mechanical ventilation with a peak pressure of 25 mmHg and inspired oxygen fraction of 0.4, was 157±28 mmHg. The mean pulmonary artery pressures were reduced to 29±3,4 from 66±15 mmHg before transplantation. Postoperative complications included rethoracotomy due to bleeding (n=4) and temporary left ventricular failure (n=4). Median ICU stay was 12 days. Incidence of rejection within the first 100 days was 0.4 per patient. Conclusion: BLTX with intraoperative and postoperatively prolonged ECMO support provides excellent initial organ function due to optimal controlled reperfusion and non-aggressive ventilation. This results in improved outcome even in advanced forms of PH.

Key Words: Lung transplantation • Pulmonary hypertension • Cardiopulmonary bypass • Extracorporeal membrane oxygenation

Abbreviations: LTX, lung transplantation • PH, pulmonary hypertension • CPB, cardiopulmonary bypass • ECMO, extracorporeal membrane oxygenation • sysPAP, systolic pulmonary artery pressure • mPAP, mean pulmonary artery pressure • ICU, intensive care unit • TX, transplantation • PaO₂, arterial oxygen pressure • FiO₂, inspired oxygen fraction • PEEP, positive end-expiratory pressure • LVF, left ventricular failure • BLTX, bilateral lung transplantation • CO, cardiac output • PPH, primary pulmonary hypertension • CF, cystic fibrosis • COPD, chronic obstructive pulmonary disease • GVH, graft versus host • SPH, secondary pulmonary hypertension • PTEA, pulmonary trombendarterectomy • PA, pulmonary aneurysm • BMI, body mass index • ETCO₂, end-tidal carbon dioxide pressure • ARDS, adult respiratory distress syndrome • I/E, inspirium–expirium ratio • ATG, antithymocyte globulin • BOS, bronchiolitis obliterans syndrome

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