Thoracic: AATS 2022 Expert Consensus Document: The Use of Mechanical Circulatory Support in Lung TransplantationThe American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation
Section snippets
The AATS Clinical Practice Standards Committee and Assembly of Expert Group
The Clinical Practice Standards Committee (CPSC) co-chairs and members of the committee were appointed by the AATS. The CPSC committee selected the topic of utilization of MCS in lung transplantation recipients. The co-chairs of the CPSC then assembled a writing group of published experts on lung transplantation, especially with the use of MCS, as well as individuals with experience in clinical practice guideline development, evidence-based medicine, research, systematic review preparation, or
Section 1a: Preoperative Pulmonary Failure
Although early referral and timely transplantation represent the ideal approach to lung transplantation, a patient's disease progression often requires bridging strategies with extracorporeal pulmonary support systems. These support strategies include extracorporeal membrane oxygenation and CO2 removal technologies to supplement or entirely replace the pulmonary function of a candidate awaiting transplantation. The principal goals of these strategies are to restore acceptable oxygenation and
Section 1b: Preoperative Cardiopulmonary Support for the Lung Transplantation Candidate
Although VV-ECMO is the first choice for support of end-stage, isolated respiratory failure in candidates being bridged to lung transplantation, end-stage lung failure caused by increased pulmonary vascular resistance may be better treated by volume-unloading the right ventricle and preserving arterial oxygenation and flow. This is best achieved by VA-ECMO treatment. Because of the need to cannulate peripheral arteries to gain access for sufficient flow, VA-ECMO has a higher complication rate
Section 1c: Special Circumstances for Preoperative Bridging With MCS
Although the use of MCS is worth considering for all patients approaching lung transplantation, some special use circumstances merit additional consideration. This section addresses 3 of these circumstances: patients with Coronavirus disease 2019 (COVID-19), patients with severe pulmonary hypertension, and patients with uncontrolled pulmonary sepsis.
Section 2a: Should Routine Lung Transplantation be Performed With or Without Mechanical Support?
Historically, the first reported double lung transplantations were performed with mechanical support. These en bloc transplantations with a tracheal anastomosis required CPB. With the development of bilateral sequential techniques of lung transplantation and the change from sternotomy to anterolateral thoracotomies/clamshell incisions, it became possible to perform lung transplantation without mechanical support.
The use of mechanical support devices provides several advantages in routine lung
Section 2b: What Is the Optimal Support Strategy if Intraoperative Support Is Necessary, and what Is the Optimal Mechanical Support for Patients Bridged to Lung Transplantation With ECMO?
The traditional intraoperative support system during lung transplantation has been CPB.86 In the past decade, VA-ECMO has become more popular, and it recently replaced CPB in the majority of centers.57, 58, 59, 60, 61,73 This trend is based on several specific advantages that ECMO offers, including low or no anticoagulation, a closed circulation system without suction, and lower proinflammatory potential without breaching the air–blood interface. In contrast, the use of CPB requires full
Section 3a: Which Patients Should Be Maintained on MCS After Lung Transplantation?
Once lung transplantation is performed under mechanical support, the question of weaning from MCS (timing and the procedure itself) is raised. Indeed, the use of ECMO during lung transplantation has changed the approach of many institutions because it facilitates the opportunity to prolong support after the surgical procedure.
Maintaining support after lung transplantation with ECMO provides several advantages during the early postoperative period. It secures immediate hemodynamic and
Section 3b: What is the Optimal Mechanical Support for PGD after Lung Transplantation?
It is well recognized that 1-year survival is compromised in patients with severe PGD following lung transplantation.113 In addition to prolonged ventilatory and pharmacologic support, ECMO as a BTR is an important adjunct to support patients with rapid onset of PGD who are not improving within the first 6 to 12 hours after lung transplantation.94 Based on data from the UNOS Registry for 2015 and 2016, approximately 5% of all lung transplant recipients required ECMO support following
Conclusions
Lung transplantation is a challenging endeavor requiring a team of dedicated individuals to navigate a complex set of clinical situations. As with many aspects of medicine, insufficient data are available to provide clear answers about the optimal path for many of these situations. We convened a group of experts to systematically review the available literature on the use of MCS in lung transplantation and to determine recommended use criteria for MCS in the peritransplantation period. In this
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