10-Year Experience with Postoperatively Extended Intraoperative Extracorporeal Membrane Oxygenation in Lung Transplantation for Patients with Severe Pulmonary Hypertension

Objectives: Bilateral lung transplantation has replaced combined heart and lung transplantation as ultimate therapeutic option for severe pulmonary hypertension (sPHT). At our institution, since early 2010, patients with severe pulmonary hypertension have been transplanted using a protocol based on postoperative extension of intraoperatively started venoarterial extracorporeal membrane oxygenation (vaECMO) support. Here we present our 10-year experience with bilateral lung transplantation using vaECMO support in patients with severe pulmonary hypertension.

Methods: Records of patients transplanted at our institution between May 2010 and August 2020 were retrospectively reviewed. Prevalence of primary graft dysfunction (PGD) grade 3 at 24, 48, and 72 hours after transplantation and ventilation time were compared between patients transplanted for severe pulmonary hypertension versus patients transplanted for other indications (control group), using chi-square test and Mann–Whitney U-test, respectively. Outcomes, such as graft survival and freedom from chronic lung allograft dysfunction (CLAD), were compared between groups using Kaplan–Meyer analysis with the log-rank test.

Result: During the study period, among the 1,234 lung-transplanted patients at our institution, 77 (6.2%) patients were transplanted for sPAH and 1,157 (93.8%) patients for other indications. Patients with severe pulmonary hypertension were younger than control patients (32.2 vs. 52 years, p < 0.0001). Prevalence of PGD grade 3 was higher in sPHT than in the control group at 24 hours (22 vs. 6%; p < 0.0001), 48 hours (24 vs. 5%; p < 0.0001), and 72 hours (25 vs. 4%; p < 0.0001). Postoperative ventilation time was significantly longer in sPHT than in the control group (11 vs. 3.5 days; p < 0.0001). Forced expiratory volume in 1 second (% predicted) at 1-year follow-up was lower in sPHT patients compared with controls (76 vs. 86%; p = 0.0007). Five- and 8-year overall graft survival (68 vs. 71%, 68 vs. 62%, p = 0.661), freedom from CLAD (72 vs. 67%, 51 vs. 58%, p = 0.902), and survival conditioned to hospital discharge (79 vs. 77%, 79 vs. 69%, p = 0.534) did not differ between sPHT and control patients.

Conclusion: A protocol based on postoperatively extended intraoperative ECMO support allows safe transplantation of sPHT patients. The more severe early postoperative course in sPHT patients is highly related to the severe complexity of the underlying disease and does not translate into a worse long-term survival and higher incidence of CLAD.

Publication History

Article published online:
19 February 2021