Extracorporeal membrane oxygenation in lung transplantation: Indications, techniques and results

Table 1 Different ECMO configurations in lung transplantation

ECMO configuration	Cannulation	Support provided	Patient condition	Utilizazion in LTx
VV	Peripheral (double lumen cannula in the SVC via the jugular or subclavian vein or a single lumen cannula in the femoral vein or jugular and femoral veins)	Only respiratory	Hypoxemia	Bridge to transplantation; post-operative period
VA	Peripheral (femoral vessels; jugular/subclavian vein and subclavian artery)	Respiratory + circulatory	Hypoxemia and cardiac failure	Bridge to transplantation; intra-operative; post-operative period
	Central (from right atrium to aorta)
VVA	Same as VV ECMO + an additional cannula in the subclavian artery	Respiratory + circulatory	Severe right heart dysfunction with hypoxemia	Bridge to transplantation; intra-operative; post-operative period

VV: Veno-venous; VA: Veno-arterial; VVA: Veno-venous arterial; ECMO: Extracorporeal membrane oxygenation, LTx: Lung transplantation, SVC: Superior vena cava.

Table 2 Outcomes of the main studies on extracorporeal membrane oxygenation as a bridge to lung transplantation

Ref.	Number of patients	Median duration of ECMO	Mode of ECMO	Complications	Successful bridge (%)	In-hospital mortality	1-yr survival	3-yr survival
Tipograf et al[31], 2019	121	12 d	VV (52%)	ECMO site 11%	59%	9%	88%	83%
			VA (43%)	Renal 8.3%
			VAV (2.5%)	Vascular 12%
			RA-LA (1.6%)	Cardiac arrest 9.9%
			PA-LA (0.8%)	Cerebrovascular 12%
Biscotti et al[29], 2017	72	12 d	VV (62.5%)	ECMO site 15.2%	55.6%	7.5%	90.3%	NR
			VA (31.9%)	Renal 8.3%
			VAV (4.2%)	Vascular 15.2%
			PA-LA (1.4%)	Cerebrovascular 5.5%
Hakim et al[32], 2018	30	8 d	VV (80%)	Bleeding 33%	87%	NR	85%	80%
			VA (16.7%)	Cardiac arrest 13%
			VVA (3.3%)	Cannula fracture 3%
				Thrombocytopenia 23%
				Needing paralytics 27%
Benazzo et al[33], 2019	120	5 d	VV 34%	Vascular 3.3%	80%	23.3%	69%	NR
			VA 30%	Cannula related 6.6%
			iLA 21.7%	IDC 0.8%
			VAV 0.8%
			Other 13.3%
Todd et al[27], 2017	12	2 d	VV 92%	NR	100%	0%	100%	NR
			VA 8%
Yeo et al[28], 2017	19	17.5 d	VV 79%	Bleeding 26%	73.7%	42%	57.9%	NR
			VA 16%	Infections 10.5%
			VAV 5%
Ko et al[30], 2020	27	11 d	VV 89%	Bleeding 46.7%	100%	25.9%	75%	70%
			VAV 7.4%	Infections 26.7%
			VA 3.7%	Airway 13.3%
Hoetzenecker et al[34], 2018	71	10 d	VV 42.3%	Cerebrovascular 4.2%	88.7%	NR	70%	63%
			VA 9.9%	Renal 31.7%
			PA-LA 12.7%	Bleeding 34.9%
			Other 33.8%
Ius et al[35], 2018	87	9 d	VV 73%	Bleeding 21%	78%	15%	79%	NR
			VA 37%	Renal 27%
				Vascular 10%
				Cerebrovascular 2%
				Atrial fibrillation 13%

ECMO: Extracorporeal membrane oxygenation; VV: Veno-venous; VA: Veno-arterial; VAV: Veno-arterial-venous; PA-LA: Pulmonary artery-left atrium; RA-LA: Right atrium-left atrium; NR: Not reported; iLA: Interventional Lung Assist.

Table 3 Outcomes of the main studies on extracorporeal membrane oxygenation for intraoperative support during lung transplantation

Ref.	No. of patients	Type of ECMO	Complications	PGD rates	In hospital mortality	1-yr survival	3-yr survival
Glorion et al[43], 2018	103	pECMO 47.5%	Rethoracotomy for bleeding 21.4%	72 h grade 1-2: 70.8%	12.6%	82.4%	65%
		cECMO 52.5%	Chest infections 5.8%	72 h grade 3: 33%
			Deep vein thrombosis 18.4%
			Lower limb ischemia 6.8%
Pettenuzzo et al[45], 2018	15	NR	Bleeding/surgical revision 26.6%	NR	13.3%	NR	NR
			Pulmonary thromboembolism 6.7%
			Cardiogenic shock 13.3%
			Cerebrovascular events 6.7%
			Sepsis with MOF 6.7%
			Deep vein thrombosis 26.7%
Hoetzenecker et al[6], 2018	343	cECMO 100%	Revision surgery 35%	72 h grade 0: 87.5%	NR	91%	85%
			Leg ischemia 0.6%	72 h grade 1: 5.4%
			Thromboembolic events 1.4%	72 h grade 2: 3.9%
				72 h grade 3: 3.3%
Cosgun et al[44], 2017	134	NR	Lymphocele 10.4%	48 h or 72 h grade 2 or 3: 7.3%	NR	84.2%	60%
			Limb ischemia 0.7%
			Revision for hemothorax 12%
			Local bleeding 0.7%
			Local infection 0.7%
Ius et al[4], 2018	281	NR	Rethoracotomy for bleeding 17.8%	24 h grade 2-3: 31.3%	NR	NR	74%
			Cerebrovascular events 1.8%	48 h grade 2-3: 35.2%
			Vascular complications 9.6%	72 h grade 2-3: 28.8%
Hoetzenecker et al[41], 2020	159	cECMO 100%	Wound infections 8.2%	Grade 0: 48.4%	NR	86%	NR
			Evacuation of hemothorax 8.2%	Grade 1: 4.4%
			Thromboembolic events 0%	Grade 2: 3.1%
			Local bleeding 0%	Grade 3: 2.5%
			Local infection 3.2%	Ungrad: 3.1%
Dell’Amore et al[46], 2020	38	cECMO 76%	Evacuation of hemothorax 16%	72 h grade 3: 16%	18%	76%	69%
		CPB 24%	Acute renal failure 21%
			Pneumonia 29%

ECMO: Extracorporeal membrane oxygenation; MOF: Multiorgan failure; NR: not reported; c: Central; p: Peripheral; Ungrad: Ungradable; CPB: Cardiopulmonary bypass; PGD: Primary graft dysfunction

Table 4 Outcomes of the main studies on prolonged or de novo secondary extracorporeal membrane oxygenation implant after lung transplantation

Ref.	Number of patients	Type of post-op ECMO	Median time from LTx to secondary ECMO	Weaning of second ECMO (%)
Mulvihill et al[57], 2017	107	De novo 100%	3 d	NR
Song et al[58], 2017	73	De novo 25%	26 d	50%
		Prolonged 75%
Hoetzenecker et al[6], 2018	123	Prolonged 100%	/	/

ECMO: Extracorporeal membrane oxygenation; LTx: Lung transplantation.