Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation Charles W. Hoopes, MD, Jasleen Kukreja, MD, Jeffery Golden, MD, Daniel L.

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Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation Charles W. Hoopes, MD, Jasleen Kukreja, MD, Jeffery Golden, MD, Daniel L. Davenport, PhD, Enrique Diaz-Guzman, MD, Joseph B. Zwischenberger, MD The Journal of Thoracic and Cardiovascular Surgery Volume 145, Issue 3, Pages 862-868 (March 2013) DOI: 10.1016/j.jtcvs.2012.12.022 Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Management algorithm for potential bridge to transplant candidates. All hemodynamically unstable patients with respiratory or cardiopulmonary failure and patients requiring transport were stabilized with femoral venoarterial (VA) extracorporeal membrane oxygenation (ECMO). Within 72 hours of deployment, patients who are awake (“neuro intact”) and without inotropic requirement have the ECMO blood path reversed (femoral arteriovenous [AV] ECMO) without centrifugal pump support (pumpless extracorporeal lung assist [PECLA]). Patients tolerating PECLA were converted to venovenous (VV) dual lumen cannula (DLC) support in preparation for ambulation. Patients with ongoing need for inotropic or centrifugal pump support were converted to central cannulation or hybrid venoarteriovenous (VAV) ECMO in preparation for ambulation. pAO2, Arterial partial pressure of oxygen; pCO2, partial pressure of carbon dioxide; MV, mechanical ventilation; hrs, hours; trach, tracheostomy; neuro, neurologic; nl, normal; ECHO, echocardiogram; abnl, abnormal; BAS, balloon atrial septostomy; RA, right atrium; PA, pulmonary artery; LA, left atrium; Ao, ascending aorta. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 862-868DOI: (10.1016/j.jtcvs.2012.12.022) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Kaplan-Meier 3-year survival for patients transplanted from an extracorporeal membrane oxygenation (ECMO) bridge (Series ECMO, n = 31, green) and patients on our institutional waitlist with lung allocation system (LAS) scores greater than 50 transplanted during the same period (June 2005 through June 2012) without mechanical support (Series LAS score >50, n = 69, blue). The institutional outcomes were compared with similar patients from the United Network for Organ Sharing (UNOS) data set transplanted without ECMO support (UNOS LAS score >50 group, n = 2971, red) and UNOS registry patients supported with ECMO at transplantation (UNOS ECMO group, n = 47, purple). Survival varied significantly among the groups (log-rank P < .001). The Journal of Thoracic and Cardiovascular Surgery 2013 145, 862-868DOI: (10.1016/j.jtcvs.2012.12.022) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Institutional epidemiology of 100 sequential extracorporeal life support deployments (86 patients), single-surgeon experience (2005 to June 2012). Approximately 30% of extracorporeal membrane oxygenation (ECMO) deployments were for respiratory failure in non-United Network for Organ Sharing waitlisted patients potentially qualifying for pulmonary transplant by disease diagnosis, age, and known associated comorbidities (n = 26). Of these, 8 recovered (“bridge to recovery”). Of the remaining 18 “salvage ECMO” patients, 7 were listed for transplantation and received allografts. The remaining 11 patients had withdrawal of support in the absence of viable transplant candidacy. tx, Transplantation; OSH, outside hospital; RV, right ventricular; ILD, interstitial lung disease; PHTN, pulmonary hypertension; LV, left ventricular; HTN, hypertension; H1N1, H1N1 influenza; PGD, primary graft dysfunction. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 862-868DOI: (10.1016/j.jtcvs.2012.12.022) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions