Textbook outcome in lung transplantation: Planned venoarterial extracorporeal membrane oxygenation versus off-pump support for patients without pulmonary hypertension

https://doi.org/10.1016/j.healun.2022.07.015Get rights and content

Background

Planned venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used during bilateral orthotopic lung transplantation (BOLT) and may be superior to off-pump support for patients without pulmonary hypertension. In this single-institution study, we compared rates of textbook outcome between BOLTs performed with planned VA ECMO or off-pump support for recipients with no or mild pulmonary hypertension.

Methods

Patients with no or mild pulmonary hypertension who underwent isolated BOLT between 1/2017 and 2/2021 with planned off-pump or VA ECMO support were included. Textbook outcome was defined as freedom from intraoperative complication, 30-day reintervention, 30-day readmission, post-transplant length of stay >30 days, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, post-transplant ECMO, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Textbook outcome achievement was compared between groups using multivariable logistic regression.

Results

Two hundred thirty-seven BOLTs were included: 68 planned VA ECMO and 169 planned off-pump. 14 (20.6%) planned VA ECMO and 27 (16.0%) planned off-pump patients achieved textbook outcome. After adjustment for prior BOLT, lung allocation score, ischemic time, and intraoperative transfusions, planned VA ECMO was associated with higher odds of textbook outcome than planned off-pump support (odds ratio 3.89, 95% confidence interval 1.58-9.90, p = 0.004).

Conclusions

At our institution, planned VA ECMO for isolated BOLT was associated with higher odds of textbook outcome than planned off-pump support among patients without pulmonary hypertension. Further investigation in a multi-institutional cohort is warranted to better elucidate the utility of this strategy.

Section snippets

Data sources and study population

We conducted a single-center retrospective cohort study using institutional and United Network for Organ Sharing (UNOS) data. Adult (age ≥18) patients who underwent isolated BOLT with planned off-pump or VA ECMO support at Duke University Hospital between January 1, 2017 and February 28, 2021 were included. Follow-up was closed in November 2021. Patients who underwent multiorgan or single LTx, had moderate or severe PH (mean pulmonary artery pressure [mPAP] ≥30 mmHg on most recent

Recipient, operative, and donor characteristics

A total of 237 adult, isolated BOLT recipients with no or mild PH were included. Of those, 68 (28.7%) and 169 (71.3%) were in the planned VA ECMO and planned off-pump strata, respectively. Consistent with our standard practice, 94.6% of BOLTs in our cohort were planned off-pump before February 2020; thereafter, 85.5% were planned VA ECMO (Figure S1). Compared to planned off-pump patients, planned VA ECMO patients were more likely to have undergone prior LTx (13.2% vs 5.3%, p = 0.04). Additional

Discussion

Sequential BOLT performed off-pump using single-lung ventilation has long represented the standard planned intraoperative support strategy for BOLT recipients without PH at many institutions, including ours.4,6 However, VA ECMO is increasingly used non-selectively for all patients undergoing BOLT.18 In this study, we characterized the perioperative recovery profile of patients without PH who underwent BOLT on planned VA ECMO using the composite TO measure. We found that planned VA ECMO was

Conclusions

In this single-center analysis, we found that planned use of VA ECMO for isolated BOLT was associated with higher odds of TO achievement than planned off-pump support among patients without PH. Amidst growing enthusiasm for nonselective use of VA ECMO as the standard planned intraoperative support strategy during BOLT, our findings provide promising new evidence to support broader adoption of this strategy to improve perioperative outcomes among patients without PH. Future studies should

Author contributions

Samantha E. Halpern: conception and study design, data collection, data analysis and interpretation, drafting of the manuscript, critical revision of the manuscript, approval of the version to be published. Mary C. Wright: conception and study design, data collection, data analysis and interpretation, critical revision of the manuscript, approval of the version to be published. Gabrielle Madsen: conception and study design, data collection, data interpretation, critical revision of the

Disclosure

The authors report no conflicts of interest.

Acknowledgments

Clinical data was abstracted from the electronic medical record and adjudicated through the work of Duke PDC Outcomes Research Team (PORT): Improving Outcomes Through Analytics Award. SEH is supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number TL1TR002555. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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