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Extending selection criteria to face donor organ shortage in heart transplantation (HTx) may increase the risk of mortality. Ex-vivo normothermic perfusion (EVP) limits ischemic time allowing assessment of graft function. We investigated the outcome of HTx in 80 high-risk recipients transplanted with marginal donor and EVP-preserved grafts, from 2016 to 2021. The recipients median age was 57 years (range, 13-75), with chronic renal failure in 61%, impaired liver function in 11% and previous cardiac surgery in 90%; 80% were mechanically supported. Median RADIAL score was 3. Mean graft ischemic time was 118 ± 25 min, "out-of-body" time 420 ± 66 min and median cardiopulmonary bypass (CPB) time 228 min (126-416). In-hospital mortality was 11% and ≥moderate primary graft dysfunction 16%. At univariable analysis, CPB time and high central venous pressure were risk factors for mortality. Actuarial survival at 1 and 3 years was 83% ± 4%, and 72% ± 7%, with a median follow-up of 16 months (range 2-43). Recipient and donor ages, pre-HTx extracorporeal life support and intra-aortic balloon pump were risk factors for late mortality. In conclusion, the use of EVP allows extension of the graft pool by recruitment of marginal donors to successfully perform HTx even in high-risk recipients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Sponga, Vendramin, Salman, Ferrara, De Manna, Lechiancole, Warnecke, Dralov, Haverich, Ius, Bortolotti, Livi and Avsar.)

Background: Venous-arterial extracorporeal membrane oxygenation (ECMO) is an established technique for intraoperative cardiopulmonary support in patients undergoing lung transplantation. Patients with pulmonary fibrosis have a higher risk to require it. The aim of this study was to identify risk factors for the need of intraoperative ECMO use., Methods: Records of patients undergoing lung transplantation for pulmonary fibrosis at our institution between January 2010 and May 2018 were retrospectively reviewed. Univariate logistic regression analysis was used for statistical identification of risk factors., Results: There were 105 patients (34%) who required intraoperative ECMO support (ECMO+ group), and 203 (66%) did not (ECMO- group). Preoperative proof of pulmonary hypertension was identified as a risk factor for intraoperative ECMO support (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2-6.5; P < .01). Revealed mean pulmonary arterial pressure values exceeding 50 mm Hg and pulmonary vascular resistance values exceeding 9.4 Wood units were identified as risk factors for the need of intraoperative ECMO use with a prediction probability of 70%. Increased recipient body surface area (OR, 0.2; 95% CI, 0.1-0.5; P < .01) emerged as a protective factor against intraoperative ECMO (Hosmer-Lemeshow statistic, P = .71) as well as higher cardiac output (OR, 0.7; 95% CI, 0.6-0.9; P < .01). The postoperative course was more complicated in the ECMO+ group, whereas survival at 5 years did not differ among groups (70% vs 69%, P = .79)., Conclusions: Pulmonary hypertension with elevated pulmonary vascular resistance values predicts the need of intraoperative ECMO in patients receiving lung transplantation for pulmonary fibrosis. Although the postoperative course was more complicated in the ECMO+ group, long-term survival did not differ significantly., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Over the past decade, extracorporeal membrane oxygenation (ECMO) has replaced cardiopulmonary bypass (CPB) for cardiopulmonary support during lung transplantation at our institution. In this study, we present our experience using intraoperative ECMO in isolated lung transplantation and evaluate its impact on long-term graft function and survival., Methods: All patients undergoing isolated lung transplantation with or without ECMO support between January 2010 and June 2019 were evaluated. Patients transplanted using CPB were excluded. Peri-operative and follow-up results from our database and patient charts were analyzed. Follow-up continued until September 1, 2019 (median, 3.34 years)., Results: In total, 311 of 1,161 lung transplant recipients (27%) received intraoperative ECMO, with 24 (2%) patients further requiring CPB. None of the remaining 826 (71%) patients required intraoperative cardiopulmonary support. ECMO patients exhibited higher pre-transplant surgical risk profiles and endured more complicated early post-operative courses than those without ECMO (in-hospital mortality, 10.9% vs 2.3%; p < 0.001). Inevitably, this resulted in poorer overall graft survival among ECMO recipients (p = 0.0025). However, correcting for patients surviving to hospital discharge, no difference in survival between groups was observed (5-year survival, 71% vs 72%; p = 0.56). Similarly, freedom from chronic lung allograft dysfunction, biopsy-confirmed cellular rejection, or need for pulsed-steroid therapy did not differ between the groups (p = 0.99, p = 0.78, and p = 0.93, respectively)., Conclusions: Compared with patients not requiring cardiopulmonary support, ECMO recipients endured a more complicated peri-operative and early post-operative course. However, among those surviving to hospital discharge, no differences in long-term complications or outcomes were observed., (Copyright © 2020 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: Extracorporeal membrane oxygenation (ECMO) has an important role in bridging patients to lung transplantation. In this study, we present our experience with pretransplant ECMO during the last 7 years and investigate its impact on graft outcomes., Methods: Records of all lung-transplanted patients at our institution between January 2010 and April 2017 were retrospectively reviewed. Graft survival was compared between patients who required pretransplant ECMO (pre-Tx ECMO+) and patients who did not (pre-Tx ECMO-). Risk factors for in-hospital mortality and graft survival were identified using a binary logistic regression and the Cox regression analyses, respectively., Results: Among the 917 patients transplanted during the study period, 68 (7%) required ECMO as a bridge to transplantation [awake strategy, n = 57 (84%) patients]. Median bridging time was 9 days. Among pre-Tx ECMO+ patients, the need for haemodialysis at any point during bridging emerged as an independent risk factor for in-hospital mortality (odds ratio 7.79, 95% confidence interval 1.21-50.24; P = 0.031). Although in-hospital mortality was significantly higher in pre-Tx ECMO+ versus pre-Tx ECMO- patients (15% vs 5%, P = 0.003), overall graft survival did not differ between groups (79% vs 90% and 61% vs 68% at 1 and 5 years, respectively, P = 0.13). Pretransplant ECMO did not emerge as a risk factor for graft survival in the multivariable analysis., Conclusions: If applied in selected patients in a high-volume centre, pretransplant ECMO as a bridge to transplantation results in impaired, but still high in-hospital, survival and does not impact graft survival.

Objectives: In severe pulmonary hypertension, diastolic dysfunction of the left ventricle causes significant morbidity and mortality after lung transplantation, which may be successfully reversed using a protocol based on perioperative veno-arterial extracorporeal membrane oxygenation (ECMO) and early extubation. Here, we present echocardiographic data and mid-term outcomes., Methods: The records of lung transplanted patients at our institution between May 2010 and January 2016 were retrospectively reviewed. Echocardiography data were collected preoperatively, at discharge, 3 and 12 months after transplantation., Results: During the study period, 717 patients underwent lung transplantation at our institution, 38 (5%) patients being transplanted for severe pulmonary hypertension. All patients underwent bilateral lung transplantation on veno-arterial ECMO cannulated in the groin, through a sternum sparing thoracotomy in 36 (95%) patients. Extubation was performed early, after a median of 2 days, and awake ECMO was extended for at least 5 days after transplantation. The survival at 3 months, 1 year and 5 years was not different in comparison to patients transplanted for other underlying diseases ( P  = 0.45). At 1 year, tricuspid valve regurgitation had disappeared in all patients. The median of the left ventricular end-diastolic dimension improved from 40 (32-44) mm preoperatively to 45 (44-47) mm at 12 months after lung transplantation ( P  < 0.05). The median of the proximal right ventricular outflow diameter decreased to 25 (23-27) mm after 12 months, compared to 48 (43-51) mm preoperatively ( P  < 0.05)., Conclusions: The routine application of a prophylactic postoperative veno-arterial ECMO protocol in patients with severe pulmonary hypertension undergoing lung transplantation decreases postoperative mortality and favours achievement of normal cardiac function after 1 year., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Since April 2010, extracorporeal membrane oxygenation (ECMO) has replaced cardiopulmonary bypass for intraoperative support during lung transplantation at our institution. The aim of this study was to present our 5-year experience with this technique., Methods: Records of patients who underwent transplantation between April 2010 and January 2015 were retrospectively reviewed. Patients who underwent transplantation without ECMO formed Group A. Patients in whom the indication for ECMO support was set a priori before the beginning of the operation formed Group B. The remaining patients in whom the indication for ECMO support was set during transplantation formed Group C., Results: Among 595 patients, 425 (71%) patients (Group A) did not require intraoperative ECMO; the remaining 170 (29%) patients did. Among these patients, 95 (56%) patients formed Group B, and the remaining 75 (44%) patients comprised Group C. Pulmonary fibrosis and pre-operative dilated or hypertrophied right ventricle emerged as risk factors for the indication of non-a priori intraoperative ECMO. Patients in Groups B and C showed a higher pre-operative risk profile and higher prevalence of post-operative complications than patients in Group A. Overall survival at 1 year was 93%, 83%, and 82% and at 4 years was 73%, 68%, and 69% in Groups A, B, and C (p = 0.11). The intraoperative use of ECMO did not emerge as a risk factor for in-hospital mortality or mortality after hospital discharge., Conclusions: Intraoperative ECMO filled the gap between pre-operative and post-operative ECMO in lung transplantation. Although complications and in-hospital mortality were higher in patients who received ECMO, survival was similar among patients who underwent transplantation with or without ECMO., (Copyright © 2016 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: Patients with respiratory failure may benefit from veno-venous and veno-arterial extracorporeal membrane oxygenation (ECMO) support. We report on our initial experience of veno-veno-arterial (v-v-a) ECMO in patients with respiratory failure., Methods: Between January 2012 and February 2014, 406 patients required ECMO support at our institution. Here, we retrospectively analysed the characteristics and outcomes of patients commenced on either veno-venous or veno-arterial ECMO due to respiratory failure, and then switched to v-v-a ECMO., Results: Ten (2%) patients proceeded to v-v-a ECMO. The underlying conditions were acute respiratory distress syndrome (n = 3), end-stage pulmonary fibrosis (n = 5) and respiratory failure after major thoracic surgery (n = 1) and Caesarean section (n = 1). In all of these patients, ECMO was initially started as veno-venous (n = 9) or veno-arterial (n = 1) ECMO but was switched to a veno-veno-arterial (v-v-a) approach after a mean of 2 (range, 0-7) days. Reasons for switching were: haemodynamic instability (right heart failure, n = 5; pericardial tamponade, n = 1; severe mitral valve regurgitation, n = 1; haemodynamic instability following cardiopulmonary resuscitation, n = 1 and evidence of previously unknown atrial septal defect with pulmonary hypertension and Eisenmenger syndrome, n = 1) and upper-body hypoxaemia (n = 1). ECMO-related complications were bleeding (n = 3) and leg ischaemia (n = 2). Seven patients were successfully taken off ECMO with 4 being bridged to recovery and a further 3 to lung transplantation after a mean of 11 (range, 9-18) days. Five patients survived until hospital discharge and all of them were alive at the end of the follow-up., Conclusions: Veno-veno-arterial ECMO is a technically feasible rescue strategy in treating patients presenting with combined respiratory and haemodynamic failure., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Bilateral lung transplantation (BLTx) is an established treatment for end-stage pulmonary hypertension (PH). Ventilator weaning failure and death are more common as in BLTx for other indications. We hypothesized that left ventricular (LV) dysfunction is the main cause of early postoperative morbidity or mortality and investigated a weaning strategy using awake venoarterial extracorporeal membrane oxygenation (ECMO)., Methods: In 23 BLTx for severe PH, ECMO used during BLTx was continued for a minimum of 5 days (BLTx-ECMO group). Echocardiography, left atrial (LA) and Swan-Ganz catheters were used for monitoring. Early extubation after transplantation was attempted under continued ECMO., Results: Preoperatively, all patients had severely reduced cardiac index (mean, 2.1 L/min/m2). On postoperative day 2, reduction of ECMO flow resulted in increasing LA and decreasing systemic blood pressures. On the day of ECMO explantation (median, postoperative day 8), LV diameter had increased; LA and blood pressures remained stable. Survival rates at 3 and 12 months were 100% and 96%, respectively. Data were compared to two historic control groups of BLTx without ECMO (BLTx ventilation) or combined heart-lung transplantation for severe PH., Conclusion: Early after BLTx for severe PH, the LV may be unable to handle normalized LV preload. This can be effectively bridged with awake venoarterial ECMO.

Objectives: Patients requiring extracorporeal cardiorespiratory support during lung transplantation can be treated with conventional cardiopulmonary bypass (CPB) or venoarterial extracorporeal membrane oxygenation (ECMO). In a retrospective analysis, we compared the postoperative course and outcomes of patients treated using these approaches., Methods: Between August 2008 and September 2011, 92 consecutive patients underwent lung transplantation with extracorporeal support (CPB group, n = 46; and, since February 2010, ECMO group, n = 46) at our institution. We evaluated survival, secondary organ failure, bleeding complications, and the need for blood and platelet transfusions in these 2 patient populations., Results: Intraoperatively, the CPB group required more packed red blood cell transfusions (12 ± 11 vs 7 ± 9 U; P = .01) and platelet concentrates (2.5 ± 1.6 vs 1.5 ± 1 U; P < .01) than the ECMO group. In-hospital mortality (39% vs 13%; P = .004), the need for hemodialysis (48% vs 13%; P < .01), and new postoperative ECMO support (26% vs 4%; P < .01) were greater in the CPB group than in the ECMO group, respectively. After propensity score analysis, multivariate analysis identified retransplantation (odds ratio, 7; 95% confidence interval, 1-43; P = .034) and transplantation with CPB support (odds ratio, 4.9; 95% confidence interval, 1.2-20; P = .026) as independent risk factors for in-hospital mortality. The survival rate at 3, 9, and 12 months was 70%, 59%, and 56% in the CPB group and 87%, 81%, and 81% in the ECMO group (P = .004)., Conclusions: Intraoperative ECMO allows for better periprocedural management and reduced postoperative complications and confers a survival benefit compared with CPB, mainly because of lower in-hospital mortality. It is now the standard of care in our lung transplantation program., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

At our institution, patients with severe pulmonary arterial hypertension (sPAH) undergo lung transplantation using a protocol based on postoperative extension of intraoperatively initiated veno-arterial extracorporeal membrane oxygenation (vaECMO) support. Here we present our 12-year experience with this protocol. Records of patients transplanted at our institution between May 2010 and September 2022 were retrospectively reviewed. Outcomes were compared between sPAH patients and patients transplanted for all the other indications. Prevalence of primary graft dysfunction (PGD) grade 3 and intensive care unit (ICU) stay time were compared using Chi-squared test and Mann-Whitney-U test, respectively. Graft survival and freedom from chronic lung allograft dysfunction (CLAD) were compared using Kaplan-Meyer analysis with the log-rank test and were further analysed by propensity score analysis. Among the 1419 lung transplanted patients, 90 (6.3%) were transplanted for sPAH and 1329 (93.6%) for other indications. Patients with sPAH were younger (33 vs. 53 years, p<0.0001) and prevalence of PGD grade 3 was higher at 24h (21% vs. 5%; p<0.0001), 48h (22% vs 5%; p<0.0001) and 72h (22 vs. 4%; p<0.0001) in comparison to control patients. Median postoperative ICU stay time was longer in sPAH patients (13 vs. 2 days; p<0.0001). 1-, 6- and 12-year survival (86.5% vs. 90.8%, 61.2% vs. 67.9%, 52% vs. 48.1% p=0.347), freedom from CLAD during follow up (96.8% vs. 96.6%, 65.8% vs. 66.1%, 57.3% vs. 54.9% p=0.955) and survival conditioned to hospital discharge (94.9% vs. 95.1%, 73% vs. 73.3%, 65.5% vs. 53% p=0.556) did not differ in sPAH vs. control patients. According to propensity score analysis, sPAH did not appear be associated with increased mortality, CLAD or mortality conditioned to hospital discharge. A protocol based on postoperatively extended intraoperative vaECMO support allows safe transplantation of patients with sPAH. Despite increased morbidity in the early postoperative period, long-term survival and freedom from CLAD were not reduced and negatively affected by sPAH. [ABSTRACT FROM AUTHOR]

At our institution, since early 2010, patients with severe pulmonary hypertension have been transplanted using a protocol based on postoperative extension of intraoperatively-started veno-arterial 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. Records of patients transplanted at our institution between January 2010 and October 2020 were retrospectively reviewed. Prevalence of primary graft dysfunction (PGD) and ventilation time were compared between patients transplanted for severe pulmonary hypertension vs. patients transplanted for other indications (control group), using Chi-Square test and Mann-Whitney U test, respectively. Graft survival and freedom from chronic lung allograft dysfunction (CLAD), were compared between groups using Kaplan-Meyer analysis with the log-rank test. During the study period, among the 1288 lung transplanted patients at our institution, 85 (6.2%) patients were transplanted for sPAH and 1201 (93.8%) patients for other indications. Patients with severe pulmonary hypertension were younger than control patients (31 vs. 47 years, p<0.0001). Prevalence of PGD grade 3 was higher in sPHT than in the control group at 24h (22% vs. 5%; p<0.0001), 48h (23% vs 5%; p<0.0001) and 72h (24 vs. 4%; p<0.0001). Mean postoperative ventilation time was significantly longer in sPHT than in the control group (11.4 vs. 3.5 days; p<0.0001). 1-, 5- and 10-year overall patient and graft survival (86% vs. 90%, 68% vs. 70%, 54% vs. 57% p=0.769), freedom from CLAD during follow up (97% vs. 96%, 75% vs. 67%, 60% vs. 52% p=0.391) and survival conditioned to hospital discharge (94% vs. 95%, 80% vs. 76%, 69% vs. 64% p=0.328) did not differ between sPHT and control patients. A protocol based on postoperatively-extended intraoperative ECMO support allows safe transplantation of sPHT patients. Despite increased morbidity in the early postoperative period, long-term survival and freedom from CLAD do not differ compared to patients who were transplanted for other indications. [ABSTRACT FROM AUTHOR]

In lung transplantation, intraoperative extracorporeal membrane oxygenation (ECMO) allows transplanting high-risk patients, such as those with idiopathic pulmonary arterial hypertension (iPAH). However, early postoperative course is more complicated in patients with than without ECMO, with higher prevalence of severe primary graft dysfunction (PGD), a risk factor for chronic lung allograft dysfunction (CLAD). Aim of this retrospective study was to test the hypothesis if the worse early postoperative course in ECMO patients translates in a worse long-term graft function too. Our institutional lung database was searched for patients who were transplanted with intraoperative ECMO between January 2010 and September 2019. Perioperative and follow-up results were compared between patients transplanted with ECMO and without ECMO. Follow-up amounted to a median of 41 (19-71) months. During the study period, among the 1,189 lung-transplanted patients, 316 (27%) patients required ECMO and the remaining 848 (71%) patients did not. Twenty-four (2%) patients requiring intraoperative cardiopulmonary bypass (CPB) support were excluded. ECMO patients showed a higher pre-transplant surgical risk profile (iPAH, 23% vs 0%, p<0.001; lung fibrosis, 42% vs 28%, p<0.001; ECMO as bridge to transplantation, 25% vs 0, p<0.001; median LAS score 42.2 vs 34.8, p<0.001) and a more complicated early postoperative course (PGD grade 3 at 72 hours, 15% vs. 1%, p<0.001; in-hospital mortality, 11% vs 2%, p<0.001) than patients without ECMO. While graft survival was worse in patients with than in patients without ECMO, freedom from CLAD, biopsy-confirmed rejection and pulsed-steroid therapy did not differ between groups (figure 1). The worse graft survival in ECMO patients was driven by a higher in-hospital mortality, but graft function at follow-up did not differ in discharged patients transplanted with and without ECMO. [ABSTRACT FROM AUTHOR]

Purpose V-a extracorporeal membrane oxygenation (ECMO) has been successfully used for intraoperative cardiopulmonary support in patients undergoing lung transplantation. Especially patients with lung fibrosis are at risk to require intraoperative v-a ECMO. Aim of this study was to identify predisposing risk factors for intraoperative ECMO support and postoperative outcomes in this cohort of patients. Methods Patients transplanted for lung fibrosis between January 2010 and May 2018 were included into the study. Patients transplanted on v-a ECMO formed group A, the remaining, group B. Follow-up amounted to a mean of 37±27 months. Multivariate forward and backward logistic regression analysis was used to identify risk factors for ECMO. Results Among the 1042 lung-transplanted patients, 313 (30%) patients underwent bilateral transplantation for lung fibrosis. Five patients were excluded as they received conventional cardiopulmonary support due to different resaons. Among the remaining 308 patients, 109 (35%) patients formed group A, 199 (65%), group B. Presence of pulmonary hypertension (OR 3.1; 95%CI 1.8-5.3, p<0.01) and a dilated and hypertrophied right ventricle (OR 2.6 95%CI 1.4-4.9, p<0.01) were identified as risk factors for ECMO support. A PVR value exceeding 575 dynes-sec-cm−5 predicted the need of ECMO with a sensitivity of 76%. Decreased cardiac index is a risk factor for ECMO support, but did not reach significance in our study (OR 0.7; 95%CI 0.47-1.03, p=0.06). Higher recipient body surface area (BSA, OR 0.3; 95%CI 0.1-0.7, p=0.01) was a protective factor against intraoperative ECMO (H-L statistic, p=0.91). Postoperatively, more group A than B patients showed primary graft dysfunction grade 2 or 3 at 72 hours (25% vs. 14%, p=0.01), required re-thoracotomy for bleeding (7% vs. 1%, p<0.01) and temporary dialysis (16% vs. 5%, p<0.01). Survival at 5 years did not significantly differ in both groups (62% vs. 58%, p=0.63). Conclusion Smaller recipient BSA, pulmonary hypertension with high PVR values and evidence of a dilated and hypertrophic right ventricle can predict the need for intraoperative ECMO in patients transplanted for lung fibrosis. Although the postoperative course was more complicated in group A than B, long-term survival did not differ between groups. [ABSTRACT FROM AUTHOR]