Ann Thorac Surg 2009;88:e56-e57. doi:10.1016/j.athoracsur.2009.07.089
© 2009 The Society of Thoracic Surgeons
Case Reports
Extracorporeal Membrane Oxygenation Bridging to Living-Donor Lobar Lung Transplantation
Kentaroh Miyoshi, MDa,
Takahiro Oto, MDa,*,
Mikio Okazaki, MDa,
Masaomi Yamane, MDa,
Shinichi Toyooka, MDa,
Keiji Goto, MDb,
Yoshifumi Sano, MDa,
Shunji Sano, MDc,
Shinichiro Miyoshi, MDa
a Department of Cancer and Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
b Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
c Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
Accepted for publication July 30, 2009.
* Address correspondence to Dr Oto, Department of Cancer and Thoracic Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan (Email: oto{at}md.okayama-u.ac.jp).
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Abstract
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A 21-year-old man with pulmonary fibrosis and a 27-year-old woman with idiopathic pulmonary hypertension, who were in pulmonary hypertensive crisis, were successfully treated by using venoarterial extracorporeal membrane oxygenation, followed by living-donor lobar lung transplantation. In both of the patients, bridging time of extracorporeal membrane oxygenation to lung transplantation was 2 days, and both could be weaned from cardiopulmonary support immediately after transplantation in the operating room. No major complications were seen, including primary graft dysfunction. The cardiopulmonary functions of these patients markedly improved after living-donor lobar lung transplantation.
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Introduction
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Lung transplantation (LTx) has been technically established as a therapeutic option for various end-stage pulmonary diseases, but primary or secondary pulmonary hypertension with severe right heart failure occasionally progress to cardiac decompensation before LTx. This life-threatening condition, so-called pulmonary hypertensive crisis, is likely to be a cause of death during the waiting time.
The use of extracorporeal membrane oxygenation (ECMO) as a bridge to LTx for such situations remains controversial [1]. With the developments of new materials and techniques for ECMO [2], the use of not only venovenous but also venoarterial (VA) ECMO has been recently reported as a bridge to LTx for patients with respiratory or cardiac decompensation [3–5]. However, prolonged duration of VA-ECMO may cause some critical complications that associate with a high risk of death, and this therapeutic strategy may be unpractical for most patients waiting for organ donation from brain-dead donors. One of the advantages of living-donor LTx is that it needs no waiting time. It seems the only realistic LTx option in countries such as Japan with a serious problem of donor shortage.
We describe two cases of successful use of VA-ECMO bridging to early living-donor lobar LTx for pulmonary hypertensive crisis. This therapeutic strategy has a potential for critically ill patient in such emergent settings.
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Case Reports
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Patient 1
A 21-year-old man with inborn juvenile rheumatoid arthritis was referred to our institution because of progressive dyspnea and systemic edema associated with pulmonary fibrosis and secondary pulmonary hypertension. Although he had received maximum medical treatment with steroids and immunosuppressants since the age of 2 years, no remarkable response had been seen. Physical activity had been limited due to hypoxia, even with 14 L/min oxygen inhalation.
A chest roentgenogram showed a severe interstitial shadow and multiple bullae in the bilateral lung field with cardiomegaly. An echocardiogram demonstrated excessive dilatation and deteriorated contraction of the right heart, with intact left ventricular contraction and a left ejection fraction of 0.89. The patient was considered as a candidate for brain-dead donor LTx. Cardiogenic shock rapidly developed, which was considered a pulmonary hypertensive crisis. VA-ECMO was initiated immediately after informed consent for living-donor LTx. His parents underwent systemic evaluation for lobar donation, and both ethically and physically cleared our institutional donation criteria for living-donor lobar LTx.
Coagulopathy increasingly progressed and bleeding from the inguinal cannulation site increased. Bilateral living-donor lobar LTx was then performed on the third day of ECMO initiation. Because the patient was found to have dense pleural adhesion due to previous infection, the entire transplant process was performed under peripheral ECMO support without central cardiopulmonary bypass to avoid full anticoagulation.
The patient was weaned from ECMO immediately after transplantation in the operation room. He experienced neither primary graft dysfunction (PGD) nor severe bleeding, and no postoperative blood transfusion was required. The partial pressure of arterial oxygen (PaO
2)/fraction of inspired oxygen ratio (FIO2) was kept exceeding 300, and mean pulmonary arterial pressure (PAP) was stable at a range of 15 to 24 mm Hg. The patient was discharged from intensive care unit 30 days after transplantation. He has sufficient physical tolerance for daily activity after LTx.
Patient 2
A 27-year-old woman with idiopathic pulmonary hypertension failed to respond to epoprostenol therapy. An echocardiogram demonstrated excessive dilatation and deteriorated contraction of right heart with intact left ventricular contraction and a left ejection fraction of 0.80. Pulmonary artery catheterization revealed severe pulmonary hypertension (PAP: 90 systolic, 40 diastolic, 58 mean, mm Hg) without pulmonary arterial thrombosis. Pulmonary artery resistance was predicted to exceed 2000 dynes · s · cm–5 at a pulmonary capillary wedge pressure of 12 mm Hg.
Although she was administered full doses of inotropes and adequate diuretics, followed by epoprostenol, her condition rapidly deteriorated and progressed to pulmonary hypertensive crisis. After informed consent for living-donor lobar LTx, VA-ECMO was initiated. Bilateral living-donor lobar LTx was then performed on the third day of ECMO. Cardiopulmonary bypass with central cannulation was used during transplant procedure, and the patient could be weaned from the cardiopulmonary bypass without difficulty.
Her postoperative course was uneventful. The PaO
2/FIO
2 ratio was kept around 300 and mean PAP was stable at a range of 23 to 32 mm Hg. No signs of PGD were seen. The patient was discharged from intensive care unit 13 days after transplantation. An echocardiogram demonstrated a recovery from excessive right ventricle dilatation and compression of the left ventricle (Fig 1). She is doing well, with normal physical tolerance for daily activity after LTx.
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Fig 1. Echocardiograms in the transverse 2-chamber view show the left (LV) and right ventricles (RV) (A) before treatment and (B) after living-donor lobar lung transplant. Compression to LV was reduced and heart function was successfully recovered.
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Comment
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The donor shortage is a significant limiting factor for LTx, especially in Japan. The estimated waiting time for LTx is nearly 3 years, and there is less chance to receive organs for severely ill patients. Living-donor LTx seems only option to salvage a transplant candidate in an emergency setting like pulmonary hypertensive crisis. Temporary life-support by ECMO can make enough time to prepare for urgent living-donor LTx, including pretransplant donor and recipient evaluation and consent. An adequate ethical approach could be applied in both of these patients. A complete medical examination was done, and confirmation of their willingness for donation was obtained after three separate interviews. In addition, our Institutional Review Board is prepared to be flexible about meeting hours. The present therapeutic strategy was based on those maximal ethical efforts.
A few detailed reports for use of VA-ECMO as a bridge to brain-dead LTx have been published [3–5]. Authors in those reports used VA-ECMO for 10 to 14 days of bridging to LTx. However, their patients experienced some serious postoperative complications, such as hepatic and renal failure, right heart failure, PGD, and pneumonia. We performed living-donor lobar LTx 2 days after initiation of VA-ECMO in both of the current patients, and they did not experience those major complications. Considering the harmful effect of prolonged ECMO, its support period should be minimal as shown in our patients. The present therapeutic strategy allows LTx teams to arrange an optimum bridging time.
Left ventricular function is also one of the predictive factors for successful resuscitation with this therapeutic strategy. In both of the current patients, the preoperative echocardiogram showed well-retained ejection fraction of the left ventricle and excellent outcomes were achieved. The recovery of heart function can strongly affect the possibility of successful weaning from ECMO and survival for the patient. Although the extent of the possible evaluation for the patient with severe condition is usually restricted, an echocardiogram is an easily accessible and reliable way to decide indication of VA-ECMO bridging to living-donor lobar LTx.
In conclusion, we successfully used VA-ECMO bridging to urgent living-donor lobar LTx for pulmonary hypertensive crisis in 2 patients. We believe that shorter bridging time is associated with better outcome. Short ECMO bridging to urgent living-donor lobar LTx may be one of the practical options for emergency pulmonary hypertensive crisis.
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References
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- Jackson A, Cropper J, Pye R, Junius F, Malouf M, Glanville A. Use of extracorporeal membrane oxygenation as a bridge to primary lung transplant: 3 consecutive, successful cases and a review of the literature J Heart Lung Transplant 2008;27:348-352.[Medline]
- Oto T, Rosenfeldt F, Rowland M, et al. Extracorporeal membrane oxygenation after lung transplantation: Evolving technique improves outcomes Ann Thorac Surg 2004;78:1230-1235.[Abstract/Free Full Text]
- Jurmann MJ, Haverich A, Demertzis S, Schaefers HJ, Wagner TO, Borst HG. Extracorporeal membrane oxygenation as a bridge to lung transplantation Eur J Cardiothorac Surg 1991;5:94-97.[Abstract/Free Full Text]
- Gregoric ID, Chandra D, Myers TJ, Scheinin SA, Loyalka P, Kar B. Extracorporeal membrane oxygenation as a bridge to emergency heart-lung transplantation in a patient with idiopathic pulmonary arterial hypertension J Heart Lung Transplant 2008;27:466-468.[Medline]
- Broome M, Palmer K, Schersten H, Frenckner B, Nilsson F. Prolonged extracorporeal membrane oxygenation and circulatory support as bridge to lung transplant Ann Thorac Surg 2008;86:1357-1360.[Abstract/Free Full Text]
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Abstract
Introduction
