1. Extracorporeal Membrane Oxygenation Following Lung Transplantation in Adult ISKANDER AL-GITHMI, M.D., FRCSC, FRCSC (Ts & CDs), FCCP. Assistant Professor of Surgery Division of Cardiothoracic Surgery King Abdulaziz University

2. Extracorporeal Membrane Oxygenation Following Lung Transplantation Lung transplantation is well established procedure. Is the only acceptable option in selected patients with end-stage pulmonary disease refractory to max. medical treatment.

3. According to ISHLT and international registry 23,716 lung transplantation were performed worldwide as of 2006. Overall mortality following lung transplant is still notable, with one year survival is 80%.

4. How many transplant recipients require ECMO? Primary graft failure Bridge for re-do lung transplant.

5. Answer Handful- Very small series spread over the last 3 decades. 1975-1 st case of ECMO used as a bridge to lung transplant was performed 1991 Hannover group published the first report of long-term survival after using ECMO as bridge to re-do lung transplant

6. 1992- Hannover group reported the first long term (12 months) survivor after using ECMO as bridge to primary lung transplant.

7. Indications Severe Allograft Failure Bridge to bridge Bridge to transplantation

8. Primary Allograft Failure Criteria/ ISHLT: Diffuse alveolar opacities exclusively involving allograft, developing within 72 hours after lung transplantation PaO 2 / FIO 2 ratio < 200 beyond 48 hours post transplant No other cause of graft failure identified such as rejection, infection or pulmonary venous obstruction

9. Primary Graft Failure 10-30% of transplant recipients develop primary graft failure ECMO may provide lifesaving temporary support ECMO long-term efficacy is controversial

10. ECMO goals: Maintain adequate oxygenation and ventilation Decrease pulmonary artery pressure, to decrease trans-capillary gradients in pulmonary vasculature Reduce rate and tidal volume of mechanical ventilation, to limit ventilator-induce lung injury

11. Selective Use of ECMO After Lung Transplant Meyers et al – Washington University conducted a retrospective study on: 444 adult lung transplant -(1988-1998) 12 patients (2.7%) require ECMO support for severe graft failure

12. Table 1. General Characteristics of Patients Treated with ECMO PatientSexDiagnosis Transplant Type Ischemic Time, First Graft (min) Ischemic Time, 2 nd Graft (min) CPB Time (min) 1FPHSingle480NA211 2FCfBilateral300523315 3FPHSingle275NA297 4FCFBilateral330480104 5FPHBilateral265310267 6FPHBilateral270300280 7FSarcoidosisBilateral19831099 8FPHBilateral290315269 9FBronchiectasisBilateral257511204 10MIPFBilateral307363None 11FCFBilateral330 197 12FCOPDBilateral314464None PH, Pulmonary Hypertension; NA, Not Applicable; CF, Cystic Fibrosis; IPF, Idiopathic Pulmonary Fibrosis; COPD, Chronic Obstructive Pulmonary Disease

13. Table II. Response of Physiologic Profile to ECMO Support Pre-ECMO4 Hours of ECMO P Value pH7.29 ± 0.117.39 ± 0.07.005 P 02 (mm Hg) 52.2 ± 8.4230 ± 78.001 P C02 (mm Hg) 46.3 ± 11.833.9 ± 3.6.001 F 102 (%) 100 ± 059.2 ± 21.9.001 PIP (cm H 2 O) 63.3 ± 14.737.4 ± 4.0.001 PAP (mm Hg) 39.2 ± 8.918.5 ± 6.8.001 F 102, Fraction of Inspired Oxygen; PIP, Peak Inspiratory Pressure; PAP, Pulmonary Arterial Pressure

14. Table IV. Result of ECMO on Lung Recovery and Patient Survival PatientECMO StartECMO DaysWeanedOutcomeComment 1 2 3 4 5 6 7 8 9 10 11 12 010001281100010001281100 3 1 4 3 4 10 1 8 4 1 Yes No Yes No Yes Lived Died Lived Died Lived Died Lived Weaned but died 4 weeks later, brain death Failure to improve; support withdrawn Massive hemorrhage Brain death Successful retransplant Failed retransplant ECMO start, Days elapsed between lung transplant and ECMO cannulation; ECMO days, length of ECMO support; weaned, removed from ECMO circuit before death.

15. Conclusion: This data do not offer adequate information to assess ECMO risk factors.

16. Clinical Risks Factors Associated with Graft Failure After Lung Transplant Christie et al conducted cohort study on 255 consecutive lung transplants between 1991- 2000 Overall incidence of graft failure after transplant was 11.8% Multivariate analysis shows the risk factors associated with the development of graft failure were: primary pulmonary HTN, female gender, donor age 45 yrs

17. Long-term Survival of Transplant recipients After ECMO use for PGF Bermudez et al conducted a study on: 763 lung or heart-lung transplant 58 patients (7.6%) required early [0-7 days after transplant] ECMO support for PGF Mean duration of support was 5.5 days Mean follow-up was 4.5 years

18. Results

19. 30 days survival was 80% 1 year survival was 39% 5 years survival was 33% Conclusion: ECMO group survival is inferior to non ECMO group

20. Conclusions: Extracorporeal membrane oxygenation can provide acceptable support for PGF after lung transplantation. Overall benefits of ECMO in lung transplantation for PGF is still being defined. No registry exist that specifically collect ECMO data in the field of lung transplantation.

21. Thank You