Effect of mode of intraoperative support on primary graft dysfunction after lung transplant

Gabriel Loor; Stephen Huddleston; Matthew Hartwig; Brandi Bottiger; Daoud Daoud; Qi Wei; Qianzi Zhang; Fabio Ius; Gregor Warnecke; Mauricio A Villavicencio; Briana Tirabassi; Tiago Noguchi Machuca; Dirk Van Raemdonck; Anna Elisabeth Frick; Arne Neyrinck; Yoshiya Toyoda; Mohammed A Kashem; Michelle Landeweer; Satish Chandrashekaran

doi:10.1016/j.jtcvs.2021.10.076

Effect of mode of intraoperative support on primary graft dysfunction after lung transplant

J Thorac Cardiovasc Surg. 2022 Nov;164(5):1351-1361.e4. doi: 10.1016/j.jtcvs.2021.10.076. Epub 2022 Feb 4.

Authors

Gabriel Loor¹, Stephen Huddleston², Matthew Hartwig³, Brandi Bottiger⁴, Daoud Daoud⁵, Qi Wei⁵, Qianzi Zhang⁵, Fabio Ius⁶, Gregor Warnecke⁷, Mauricio A Villavicencio⁸, Briana Tirabassi⁸, Tiago Noguchi Machuca⁹, Dirk Van Raemdonck¹⁰, Anna Elisabeth Frick¹⁰, Arne Neyrinck¹¹, Yoshiya Toyoda¹², Mohammed A Kashem¹², Michelle Landeweer², Satish Chandrashekaran¹³

Affiliations

¹ Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, Tex. Electronic address: Gabriel.loor@bcm.edu.
² Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn.
³ Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Health System, Durham, NC.
⁴ Department of Anesthesiology, Duke University Health System, Durham, NC.
⁵ Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, Tex.
⁶ Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany.
⁷ Department of Cardiac Surgery, Heidelberg University Hospital, Heidelberg, Germany.
⁸ Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Mass.
⁹ Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla.
¹⁰ Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.
¹¹ Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium.
¹² Division of Cardiovascular Surgery, Temple University School of Medicine, Philadelphia, Pa.
¹³ Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Fla.

PMID: 35236625
DOI: 10.1016/j.jtcvs.2021.10.076

Abstract

Objective: To clarify the relationship between the use of extracorporeal life support during lung transplantation and severe primary graft dysfunction (PGD), we developed and analyzed a novel multicenter international registry.

Methods: The Extracorporeal Life Support in Lung Transplantation Registry includes double-lung transplants performed at 8 high-volume centers (>40/year). Multiorgan transplants were excluded. We defined severe PGD as grade 3 PGD (PGD3) observed 48 or 72 hours after reperfusion. Modes of support were no extracorporeal life support (off-pump), extracorporeal membrane oxygenation (ECMO), and cardiopulmonary bypass (CPB). To assess the association between mode of support and PGD3, we adjusted for demographic and intraoperative factors with a stepwise, mixed selection, multivariable regression model, ending with 10 covariates in the final model.

Results: We analyzed 852 transplants performed between January 2016 and March 2020: 422 (50%) off-pump, 273 (32%) ECMO, and 157 (18%) CPB cases. PGD3 rates at time point 48-72 were 12.1% (51 out of 422) for off-pump, 28.9% for ECMO (79 out of 273), and 42.7% (67 out of 157) for CPB. The adjusted model resulted in the following risk profile for PGD3: CPB versus ECMO odds ratio, 1.89 (95% CI, 1.05-3.41; P = .033), CPB versus off-pump odds ratio, 4.24 (95% CI, 2.24-8.04; P < .001), and ECMO versus off-pump odds ratio, 2.24 (95% CI, 1.38-3.65; P = .001).

Conclusions: Venoarterial ECMO is increasingly used at high-volume centers to support complex transplant recipients during double-lung transplantation. This practice is associated with more risk of PGD3 than off-pump transplantation but less risk than CPB. When extracorporeal life support is required during lung transplantation, ECMO may be the preferable approach when feasible.

Keywords: cardiopulmonary bypass; extracorporeal life support; extracorporeal membrane oxygenation; lung transplantation; outcomes; primary graft dysfunction.

Publication types

Multicenter Study
Research Support, Non-U.S. Gov't

MeSH terms

Cardiopulmonary Bypass / adverse effects
Extracorporeal Membrane Oxygenation* / adverse effects
Extracorporeal Membrane Oxygenation* / methods
Humans
Lung Transplantation* / adverse effects
Lung Transplantation* / methods
Primary Graft Dysfunction* / diagnosis
Primary Graft Dysfunction* / etiology
Primary Graft Dysfunction* / therapy
Retrospective Studies
Transplant Recipients
Treatment Outcome