Ann Thorac Surg 2001;72:1407-1408
© 2001 The Society of Thoracic Surgeons
How to do it
Extracorporeal membrane oxygenation before induction of anesthesia in critically ill thoracic transplant patients
Willem J. de Boer, MDa,
Tjalling W. Waterbolk, MDa,
Johan Brügemann, MD, PhDb,
Wim van der Bij, MD, PhDc,
Robert J. Huyzen, MDd
a Department of Cardiothoracic Surgery, University Hospital Groningen, Groningen, The Netherlands
b Department of Cardiology, University Hospital Groningen, Groningen, The Netherlands
c Department of Pulmonology, University Hospital Groningen, Groningen, The Netherlands
d Department of Anesthesiology, University Hospital Groningen, Groningen, The Netherlands
Accepted for publication May 14, 2001.
Address reprint requests to Dr de Boer, Department of Cardiothoracic Surgery, University Hospital Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
e-mail: w.j.de.boer{at}thorax.azg.nl
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Abstract
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Cardiorespiratory failure just before surgery in critically ill thoracic transplant patients can have catastrophic consequences. We judged the cardiorespiratory condition in three of 160 thoracic transplant procedures performed in our center too unstable for a safe induction of anesthesia. In these 3 patients, extracorporeal membrane oxygenation support was installed before induction of anesthesia to maintain an adequate cardiorespiratory state. This strategy was successful for all 3 patients, and long-term survival was achieved with a good quality of life. Guidelines for indications to follow this strategy are discussed.
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Introduction
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The indication for the use of cardiopulmonary bypass in thoracic transplant procedures like heart and heart-lung transplantation is certain. Cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO) support also has been applied in lung transplantation since the early developmental days, but it is not always necessary because the technique of the transplant procedure has evolved [1, 2]. The requirement for cardiopulmonary bypass in lung transplantation is, apart from the certain indications like pulmonary hypertension, usually dependent on unpredictable intraoperative factors or center specific preference [3]. For cardiorespiratory critically ill patients, sometimes resuscitation and emergency installation of cardiopulmonary bypass is needed during transplantation [4]. For these specific patients, we need to improve the safety of the transplant procedures. The number of these critically ill transplant patients is growing due to longer waiting times for transplantation caused by donor organ shortage. Furthermore, the possibilities to prioritize for high-urgent transplantation with a short waiting time are insufficient. Most of these critically ill patients do not reach the transplant or are submitted to a treatment with cardiac assist device or with extracorporeal membrane oxygenation as a bridge to transplant in an earlier stage [5]. In our experience with 160 thoracic transplant procedures (149 lung, three heart-lung, two combined lung-liver, and six heart), we fortunately did not encounter cardiorespiratory failure just before surgery with catastrophic outcome. However, 1 patient requiring lung transplantation for pulmonary hypertensive disease needed resuscitation and emergency installation of cardiopulmonary bypass after induction of anesthesia, fortunately with reasonable outcome. Recognizing cardiorespiratory arrest as a major predictor of mortality and morbidity, we developed for these critically ill patients in cardiorespiratory failure before surgery an alternative strategy to secure an adequate circulation and gas exchange. Subsequently, we judged the cardiorespiratory condition of 3 patients too unstable for a safe induction of anesthesia. For these 3 patients, we followed this alternative strategy to secure an adequate circulation and gas exchange.
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Technique
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The decision to follow the strategy of ECMO support before the transplantation was made on the direct preoperative condition of the patients. Since 1995, 3 patients were selected for this strategy when donor organs became available. The patient characteristics are summarized in Table 1. All 3 patients were in cardiorespiratory failure with low systolic blood pressure (
70 mm Hg) and low cardiac index ( 2 L/min/m2) or severe hypercapnia (pCO2 
70 mm Hg) and hypoxemia (SO2 80%), despite maximum pharmacological and inspired oxygen therapy. In the operating room, with the patient in a half sitting position and awake, the right femoral artery and vein were identified after local infiltration anesthesia. A usual bypass circuit was prepared containing membrane oxygenator, heat exchanger, reservoir, and pump, with an additional arterial and venous line. After heparinization, the arterial (14°F to 16°F) and long venous cannulas (24°F) were inserted using a needle and guidewire technique (Baxter Health Care Corporation, Irvine, CA). The 15-cm-long arterial cannula was positioned with its distal end in the iliac artery. The 52-cm-long venous cannula was positioned with its distal end within the right atrium or high in the inferior vena cava. The bypass tubing was connected, and the reached flow rates of 2.5 to 3.5 L/min were sufficient to stabilize the cardiorespiratory parameters. Induction and general anesthesia followed. The entire bilateral lung transplantation was performed with femoral venoarterial bypass support. When, during the lung transplant procedure, the femoral bypass is continued, one should be aware of a possible differential upper and lower body perfusion, which can result in an insufficient oxygenation of the upper part of the body [6]. During the heart and heart-lung transplant procedure, the superior vena cava was cannulated separate and connected to the additional venous bypass line, the ascending aorta was cannulated centrally and connected to the additional arterial bypass line to provide sufficient flow rates, and the femoral arterial cannula was removed.
The three transplantations were successfully completed. The ECMO support prolonged the total bypass time by a mean of 43 minutes (range 35 to 55 minutes). The time of graft ischemia was not prolonged due to an anticipated early beginning of the recipient operation. The postoperative course was without complications, and long-term survival was achieved for all 3 patients despite their marginal preoperative condition.
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Comment
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This strategy of ECMO support before transplantation can be advised in cardiorespiratory critically ill thoracic transplant patients when the period of induction of anesthesia is judged too hazardous, especially when adhesions are expected and it therefore takes more time to install cardiopulmonary bypass through the thoracic approach. The attractiveness of the described strategy is that it can be applied in this challenging group of patients with different diseases requiring different forms of thoracic transplantation. The aim of ECMO support is to achieve stable circulation and gas exchange before the stressful period of induction of anesthesia and to prevent further deterioration resulting in hazardous cardiorespiratory arrest. Although general rules or exact cardiorespiratory limits below which ECMO support should be applied are difficult to conclude from our limited experience, we are encouraged by the excellent outcome and formulate with caution the following indicative factors. All 3 ECMO patients had a quick deterioration of their disease requiring an urgent transplantation. All 3 patients were in cardiac failure, primary or secondary to respiratory failure, despite maximum pharmacological and inspired oxygen therapy when donor organs became available, in contrast to our other recipients. Under these conditions, we consider patients with end-stage cardiomyopathies, pulmonary vascular or parenchymal disease in severe hemodynamic instability with low systolic blood pressure ( 70 mm Hg), and low cardiac index ( 2 L/min/m2) or severe hypercapnia (pCO2 70 mm Hg) and hypoxemia (SO2 80%) eligible for the strategy of ECMO support before transplantation. The decision to follow this strategy of ECMO support can be made on the direct preoperative condition of the individual patient. In this era of giving transplant priority to the more ill patient due to donor organ shortage, efforts have to be made to safeguard thoracic transplant procedures to avoid graft loss and to improve the quality of life of the transplant patients. The technique of ECMO support before the transplantation is, in our experience, a contribution to the benefit of thoracic organ transplantation in this challenging group of patients.
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References
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Nelems J.M., Duffin J., Glynn M.F.X., Brebner J., Scott A.A., Cooper J.D. Extracorporeal membrane oxygenator support for human lung transplantation. J Thorac Cardiovasc Surg 1978;1:28-32.
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Abstract
Introduction
