Thoracic: AATS 2022 Expert Consensus Document: The Use of Mechanical Circulatory Support in Lung Transplantation
The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation

Read at the 102nd Annual Meeting of The American Association for Thoracic Surgery, Boston, Massachusetts, May 14-17, 2022.
https://doi.org/10.1016/j.jtcvs.2022.06.024Get rights and content

Abstract

Objective

The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation.

Methods

The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement.

Results

The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively.

Conclusions

Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for 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

References (129)

  • M. Biscotti et al.

    ECMO as bridge to lung transplant

    Thorac Surg Clin

    (2015)
  • J. Kukreja et al.

    Risk factors and outcomes of extracorporeal membrane oxygenation as a bridge to lung transplantation

    Semin Thorac Cardiovasc Surg

    (2020)
  • J. Javidfar et al.

    Extracorporeal membrane oxygenation as a bridge to lung transplantation and recovery

    J Thorac Cardiovasc Surg

    (2012)
  • J. Blakeslee-Carter et al.

    Vascular complications based on mode of extracorporeal membrane oxygenation

    J Vasc Surg

    (2022)
  • M.D. Moussa et al.

    Subclavian versus femoral arterial cannulations during extracorporeal membrane oxygenation: a propensity-matched comparison

    J Heart Lung Transplant

    (2022)
  • A. Bharat et al.

    Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries

    Lancet Respir Med

    (2021)
  • M. Cypel et al.

    When to consider lung transplantation for COVID-19

    Lancet Respir Med

    (2020)
  • C. Lang et al.

    Lung transplantation for COVID-19-associated acute respiratory distress syndrome in a PCR-positive patient

    Lancet Respir Med

    (2020)
  • A.E. Frick et al.

    Lung transplantation for acute respiratory distress syndrome: a multicenter experience

    Am J Transplant

    (2022)
  • M. de Perrot et al.

    Impact of extracorporeal life support on outcome in patients with idiopathic pulmonary arterial hypertension awaiting lung transplantation

    J Heart Lung Transplant

    (2011)
  • P. Downey et al.

    Ambulatory central veno-arterial extracorporeal membrane oxygenation in lung transplant candidates

    J Heart Lung Transplant

    (2019)
  • A. Rothman et al.

    Atrial septostomy as a bridge to lung transplantation in patients with severe pulmonary hypertension

    Am J Cardiol

    (1999)
  • J. Sandoval et al.

    Atrial septostomy for pulmonary hypertension

    Clin Chest Med

    (2001)
  • Z.N. Kon et al.

    Venovenous extracorporeal membrane oxygenation with atrial septostomy as a bridge to lung transplantation

    Ann Thorac Surg

    (2016)
  • M. Cypel et al.

    Bilateral pneumonectomy to treat uncontrolled sepsis in a patient awaiting lung transplantation

    J Thorac Cardiovasc Surg

    (2017)
  • Y.D. Barac et al.

    Bilateral pneumonectomy with veno-arterial extracorporeal membrane oxygenation as a bridge to lung transplant

    J Heart Lung Transplant

    (2019)
  • T.N. Machuca et al.

    Outcomes of intraoperative extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation

    J Thorac Cardiovasc Surg

    (2015)
  • F. Ius et al.

    Lung transplantation on cardiopulmonary support: venoarterial extracorporeal membrane oxygenation outperformed cardiopulmonary bypass

    J Thorac Cardiovasc Surg

    (2012)
  • W. Seeger et al.

    Pulmonary hypertension in chronic lung diseases

    J Am Coll Cardiol

    (2013)
  • F. Ius et al.

    Five-year experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: indications and midterm results

    J Heart Lung Transplant

    (2016)
  • P.R. Shah et al.

    Extracorporeal support during bilateral sequential lung transplantation in patients with pulmonary hypertension: risk factors and outcomes

    J Cardiothorac Vasc Anesth

    (2017)
  • M.S. Bhabra et al.

    Controlled reperfusion protects lung grafts during a transient early increase in permeability

    Ann Thorac Surg

    (1998)
  • M.S. Bhabra et al.

    Critical importance of the first 10 minutes of lung graft reperfusion after hypothermic storage

    Ann Thorac Surg

    (1996)
  • B.C. Sheridan et al.

    Acute and chronic effects of bilateral lung transplantation without cardiopulmonary bypass on the first transplanted lung

    Ann Thorac Surg

    (1998)
  • K. Hoetzenecker et al.

    Bilateral lung transplantation on intraoperative extracorporeal membrane oxygenator: an observational study

    J Thorac Cardiovasc Surg

    (2020)
  • K. Hoetzenecker et al.

    Intraoperative extracorporeal membrane oxygenation and the possibility of postoperative prolongation improve survival in bilateral lung transplantation

    J Thorac Cardiovasc Surg

    (2018)
  • T. Bisdas et al.

    Vascular complications in patients undergoing femoral cannulation for extracorporeal membrane oxygenation support

    Ann Thorac Surg

    (2011)
  • F. Ius et al.

    Long-term outcomes after intraoperative extracorporeal membrane oxygenation during lung transplantation

    J Heart Lung Transplant

    (2020)
  • J. Salman et al.

    Intraoperative extracorporeal circulatory support in lung transplantation for pulmonary fibrosis

    Ann Thorac Surg

    (2021)
  • J. Tomasko et al.

    Therapeutic anticoagulation-free extracorporeal membrane oxygenation as a bridge to lung transplantation

    J Heart Lung Transplant

    (2016)
  • K. Hashimoto et al.

    Intraoperative extracorporeal support during lung transplantation in patients bridged with venovenous extracorporeal membrane oxygenation

    J Heart Lung Transplant

    (2018)
  • D. Van Raemdonck et al.

    Report of the ISHLT working group on primary lung graft dysfunction Part IV: prevention and treatment: A 2016 consensus group statement of the International Society for Heart and Lung Transplantation

    J Heart Lung Transplant

    (2017)
  • D.P. Mason et al.

    Extended use of extracorporeal membrane oxygenation after lung transplantation

    J Thorac Cardiovasc Surg

    (2006)
  • M.G. Hartwig et al.

    Improved survival but marginal allograft function in patients treated with extracorporeal membrane oxygenation after lung transplantation

    Ann Thorac Surg

    (2012)
  • S. Fischer et al.

    Extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation: analysis of the Extracorporeal Life Support Organization (ELSO) registry

    J Heart Lung Transplant

    (2007)
  • P.S. Dahlberg et al.

    Medium-term results of extracorporeal membrane oxygenation for severe acute lung injury after lung transplantation

    J Heart Lung Transplant

    (2004)
  • C.H. Wigfield et al.

    Early institution of extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation improves outcome

    J Heart Lung Transplant

    (2007)
  • T. Oto et al.

    Extracorporeal membrane oxygenation after lung transplantation: evolving technique improves outcomes

    Ann Thorac Surg

    (2004)
  • L.R. Kaiser et al.

    Bilateral sequential lung transplantation: the procedure of choice for double-lung replacement

    Ann Thorac Surg

    (1991)
  • J.D. Hill et al.

    Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung

    N Engl J Med

    (1972)
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