Clinical Benefit of Lung Transplantation after ECMO Support

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Abstract

Bridge with artificial respiratory support, although now widely used, may significantly affect the results of lung transplantation (LTX), particularly in limited-volume centers. Between 2006 and 2016, 155 patients underwent lung transplantation at our center. 50 patients were bridged to possible transplantation with venovenous or venoarterial ECMO. 32 patients (64%) were successfully bridged to transplantation while 18 died on the waiting list. Overall, lung transplants after ECMO repesented 21% of all the entire transplant cohort. The average duration of ECMO support was 7 days (range 1-30). The majority (50%) of patients had cystic fibrosis. Awake ECMO was used in 8 cases before transplantation. Our supported patients had a trend to less favorable but statistically equivalent 1-, 3-, and 12-month survival compared with non-supported patients. The incidence of primary graft dysfunction (PGD) of any grade was higher in supported patients, but the rate of high-grade PGD (>2) was similar in all patients. The length of stay in the intensive care unit was 10 days longer, on average, in bridged patients. After 2010, patients bridged to LTX on ECMO received an emergency status on the waiting list. Competitive risk analysis was used to assess the overall benefit of performing transplantation in patients who were placed on ECMO and on an emergency status. The entire population of patients who were listed for LTX since the beginning of the program was analyzed. Death was the event of interest and LTX the competing event of the model. Patients on the list before 2010 and without ECMO support had the highest cumulative incidence of death and the least probability to receive a transplant (figure 1). These findings support the use of ECMO as a bridge to LTX and the overall benefit of an emergency allocation system, without any increased risk of significant worse outcome in patients who are not bridged.

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