Mid-Term Outcomes of Veno-Venous Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation: Comparison with Non-Bridged Recipients

Objectives: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is increasingly being used in acutely deteriorating patients with end-stage lung disease as a bridge to transplantation (BTT). It can allow critically ill recipients to remain eligible for lung transplant (LTx) while reducing pretransplant deconditioning. We analyzed early and mid-term postoperative outcomes of patients on VV-ECMO as a BTT and the impact of preoperative VV-ECMO on posttransplant survival outcomes. Methods: All consecutive LTx performed at our institution between January 2012 and December 2018 were analyzed. After matching, BTT patients were compared with non-bridged LTx recipients. Results: Out of 297 transplanted patients, 21 (7.1%) were placed on VV-ECMO as a BTT. After matching, we observed a similar 30-day mortality between BTT and non-BTT patients (4.6% vs. 6.6%, p=0.083) despite a higher incidence of early postoperative complications (need for ECMO, delayed chest closure, acute kidney injury). Furthermore, preoperative VV-ECMO did not appear associated with 30-day or 1-year mortality in both frequentist and Bayesian analysis (OR 0.35, 95%CI 0.03-3.49, p=0.369; OR 0.27, 95%CrI 0.01-3.82, P=84.7%, respectively). In sensitivity analysis, both subgroups were similar in respect to 30-day (7.8% vs. 6.5%, p=0.048) and 1-year mortality (12.5% vs. 18%, p=0.154). Conclusions: Patients with acute refractory respiratory failure while waiting for LTx represent a high-risk cohort of patients. We observed that these patients can be successfully bridged to LTx with VV-ECMO with post-transplant mortality comparable to non-BTT patients.

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Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0041-1728795 ◽

2021 ◽

Vol 42 (03) ◽

pp. 380-391

Author(s):

John W. Stokes ◽

Whitney D. Gannon ◽

Matthew Bacchetta

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Lung Disease ◽

Respiratory Function ◽

Lung Transplant ◽

Practice Patterns ◽

Effective Strategy ◽

Membrane Oxygenation ◽

Technological Advances ◽

Physiologic Condition ◽

End Stage

AbstractExtracorporeal membrane oxygenation (ECMO) is a cardiopulmonary technology capable of supporting cardiac and respiratory function in the presence of end-stage lung disease. Initial experiences using ECMO as a bridge to lung transplant (ECMO-BTLT) were characterized by high rates of ECMO-associated complications and poor posttransplant outcomes. More recently, ECMO-BTLT has garnered success in preserving patients' physiologic condition and candidacy prior to lung transplant due to technological advances and improved management. Despite recent growth, clinical practice surrounding use of ECMO-BTLT remains variable, with little data to inform optimal patient selection and management. Although many questions remain, the use of ECMO-BTLT has shown promising outcomes suggesting that ECMO-BTLT can be an effective strategy to ensure that complex and rapidly decompensating patients with end-stage lung disease can be safely transplanted with good outcomes. Further studies are needed to refine and inform practice patterns, management, and lung allocation in this high-risk and fragile patient population.

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Does acute kidney injury affect survival in adults with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation?

Perfusion ◽

10.1177/0267659118755272 ◽

2018 ◽

Vol 33 (5) ◽

pp. 375-382 ◽

Cited By ~ 7

Author(s):

Richard Devasagayaraj ◽

Nicholas C. Cavarocchi ◽

Hitoshi Hirose

Keyword(s):

Acute Kidney Injury ◽

Renal Failure ◽

Acute Respiratory Distress Syndrome ◽

Extracorporeal Membrane Oxygenation ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Distress Syndrome ◽

Kidney Injury ◽

Membrane Oxygenation ◽

Vv Ecmo

Introduction: Patients who develop severe acute respiratory distress syndrome (ARDS) despite full medical management may require veno-venous extracorporeal membrane oxygenation (VV ECMO) to support respiratory function. Survival outcomes remain unclear in those who develop acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) during VV ECMO for isolated severe respiratory failure in adult populations. Methods: A retrospective chart review (2010-2016) of patients who underwent VV ECMO for ARDS was conducted with university institutional review board (IRB) approval. Patients supported by veno-arterial ECMO were excluded. AKI was defined by acute renal failure receiving CRRT and the outcomes of patients on VV ECMO were compared between the AKI and non-AKI groups. Results: We identified 54 ARDS patients supported by VV ECMO (mean ECMO days 12 ± 6.7) with 16 (30%) in the AKI group and 38 (70%) in the non-AKI group. No patient had previous renal failure and the serum creatinine was not significantly different between the two groups at the time of ECMO initiation. The AKI group showed a greater incidence of complications during ECMO, including liver failure (38% vs. 5%, p=0.002) and hemorrhage (94% vs. 45%, p=0.0008). ECMO survival of the AKI group (56% [9/16]) was inferior to the non-AKI group (87% [33/38], p=0.014). Conclusions: Our study demonstrated that VV ECMO successfully manages patients with severe isolated lung injury. However, once patients develop AKI during VV ECMO, they are likely to further develop multi-organ dysfunction, including hepatic and hematological complications, leading to inferior survival.

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Incidence and Impact of Acute Kidney Injury in Patients Receiving Extracorporeal Membrane Oxygenation: A Meta-Analysis

Journal of Clinical Medicine ◽

10.3390/jcm8070981 ◽

2019 ◽

Vol 8 (7) ◽

pp. 981 ◽

Cited By ~ 13

Author(s):

Charat Thongprayoon ◽

Wisit Cheungpasitporn ◽

Ploypin Lertjitbanjong ◽

Narothama Reddy Aeddula ◽

Tarun Bathini ◽

...

Keyword(s):

Systematic Review ◽

Acute Kidney Injury ◽

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Meta Analysis ◽

Kidney Injury ◽

Incidence Rates ◽

Adult Patients ◽

Membrane Oxygenation ◽

The Impact

Background: Although acute kidney injury (AKI) is a frequent complication in patients receiving extracorporeal membrane oxygenation (ECMO), the incidence and impact of AKI on mortality among patients on ECMO remain unclear. We conducted this systematic review to summarize the incidence and impact of AKI on mortality risk among adult patients on ECMO. Methods: A literature search was performed using EMBASE, Ovid MEDLINE, and Cochrane Databases from inception until March 2019 to identify studies assessing the incidence of AKI (using a standard AKI definition), severe AKI requiring renal replacement therapy (RRT), and the impact of AKI among adult patients on ECMO. Effect estimates from the individual studies were obtained and combined utilizing random-effects, generic inverse variance method of DerSimonian-Laird. The protocol for this systematic review is registered with PROSPERO (no. CRD42018103527). Results: 41 cohort studies with a total of 10,282 adult patients receiving ECMO were enrolled. Overall, the pooled estimated incidence of AKI and severe AKI requiring RRT were 62.8% (95%CI: 52.1%–72.4%) and 44.9% (95%CI: 40.8%–49.0%), respectively. Meta-regression showed that the year of study did not significantly affect the incidence of AKI (p = 0.67) or AKI requiring RRT (p = 0.83). The pooled odds ratio (OR) of hospital mortality among patients receiving ECMO with AKI on RRT was 3.73 (95% CI, 2.87–4.85). When the analysis was limited to studies with confounder-adjusted analysis, increased hospital mortality remained significant among patients receiving ECMO with AKI requiring RRT with pooled OR of 3.32 (95% CI, 2.21–4.99). There was no publication bias as evaluated by the funnel plot and Egger’s regression asymmetry test with p = 0.62 and p = 0.17 for the incidence of AKI and severe AKI requiring RRT, respectively. Conclusion: Among patients receiving ECMO, the incidence rates of AKI and severe AKI requiring RRT are high, which has not changed over time. Patients who develop AKI requiring RRT while on ECMO carry 3.7-fold higher hospital mortality.

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A descriptive evaluation of causes of death in venovenous extracorporeal membrane oxygenation

Perfusion ◽

10.1177/02676591211035938 ◽

2021 ◽

pp. 026765912110359

Author(s):

Sagar B Dave ◽

Kristopher B Deatrick ◽

Samuel M Galvagno ◽

Michael A Mazzeffi ◽

David J Kaczorowski ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Hospital Mortality ◽

Cause Of Death ◽

Lung Transplant ◽

Acute Hemorrhage ◽

Ventilator Support ◽

Common Cause ◽

Membrane Oxygenation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

Vv Ecmo

Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become an important support modality for patients with acute respiratory failure refractory to optimal medical therapy, such as low tidal volume mechanical ventilator support, early paralytic infusion, and early prone positioning. The objective of this cohort study was to investigate the causes and timing of in-hospital mortality in patients on VV ECMO. All patients, excluding trauma and bridge to lung transplant, admitted 8/2014–6/2019 to a specialty ICU for VV ECMO were reviewed. Two hundred twenty-five patients were included. In-hospital mortality was 24.4% ( n = 55). Most non-survivors (46/55, 84%) died prior to lung recovery and decannulation from VV ECMO. Most common cause of death (COD) for patients who died on VV ECMO was removal of life sustaining therapy (LST) in setting of multisystem organ failure (MSOF) ( n = 24). Nine patients died a median of 9 days [6, 11] after decannulation. Most common COD in these patients was palliative withdrawal of LST due to poor prognosis ( n = 3). Non-survivors were older and had worse predictive mortality scores than survivors. We found that death in patients supported with VV ECMO in our study most often occurs prior to decannulation and lung recovery. This study demonstrated that the most common cause of death in patients supported with VV ECMO was removal of LST due MSOF. Acute hemorrhage (systemic or intracranial) was not found to be a common cause of death in our patient population.

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Prognosis of Patients on Extracorporeal Membrane Oxygenation: The Impact of Acute Kidney Injury on Mortality

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2010.08.063 ◽

2011 ◽

Vol 91 (1) ◽

pp. 137-142 ◽

Cited By ~ 61

Author(s):

Yung-Chang Chen ◽

Feng-Chun Tsai ◽

Chih-Hsiang Chang ◽

Chan-Yu Lin ◽

Chang-Chyi Jenq ◽

...

Keyword(s):

Acute Kidney Injury ◽

Extracorporeal Membrane Oxygenation ◽

Kidney Injury ◽

Membrane Oxygenation ◽

The Impact

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Opioid and Benzodiazepine Requirements in Obese Adult Patients Receiving Extracorporeal Membrane Oxygenation

Annals of Pharmacotherapy ◽

10.1177/1060028019872940 ◽

2019 ◽

Vol 54 (2) ◽

pp. 144-150

Author(s):

Brittany S. Verkerk ◽

Amy L. Dzierba ◽

Justin Muir ◽

Caroline Der-Nigoghossian ◽

Daniel Brodie ◽

...

Keyword(s):

Extracorporeal Membrane Oxygenation ◽

Adult Patients ◽

Obese Group ◽

Sedation Scale ◽

Richmond Agitation Sedation Scale ◽

Membrane Oxygenation ◽

Baseline Characteristics ◽

The Impact ◽

Vv Ecmo

Background: The use of extracorporeal membrane oxygenation (ECMO) sometimes requires deep levels of sedation (Richmond Agitation Sedation Scale [RASS] −5) in patients with acute respiratory distress syndrome (ARDS). The role of obesity in opioid and sedative requirements remains unclear in patients receiving ECMO. Objective: This study sought to determine whether obesity increases midazolam and opioid requirements in patients receiving venovenous (vv)-ECMO up to the first 7 days after initiation. Methods: This was a retrospective cohort study of adult patients with ARDS managed with vv-ECMO. Results: The obese (n = 38) and nonobese (n = 43) groups had similar baseline characteristics. Fentanyl equivalents were significantly higher on day 3 in the obese group ( P = 0.02) despite similar RASS scores with no differences in midazolam requirements. There were no differences in duration of ECMO, length of stay, or mortality. Conclusion and Relevance: Daily midazolam requirements were not significantly different, and opioid requirements were only significantly higher in the obese group on day 3 despite similar levels of sedation. The impact of obesity with the addition of ECMO and how to adapt doses of medications remains elusive.

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Acute Kidney Injury During Extracorporeal Membrane Oxygenation: VA ECMO Versus VV ECMO

Journal of Intensive Care Medicine ◽

10.1177/08850666211035323 ◽

2021 ◽

pp. 088506662110353

Author(s):

Zhixiang Mou ◽

Jinxuan He ◽

Tianjun Guan ◽

Lan Chen

Keyword(s):

Acute Kidney Injury ◽

Extracorporeal Membrane Oxygenation ◽

Web Of Science ◽

Meta Analysis ◽

Kidney Injury ◽

Patient Deterioration ◽

Membrane Oxygenation ◽

Different Types ◽

Va Ecmo ◽

Vv Ecmo

Purpose Acute kidney injury (AKI) has been reported to be one of the most common complications in patients receiving extracorporeal membrane oxygenation (ECMO), yet variations in AKI between different types of ECMO remain unclear. This meta-analysis systematically compares AKI/severe AKI in adult patients requiring different types of ECMO. Methods Two authors independently performed a literature search using PubMed, Web of Science, and Embase, encompassing publications up until April 20, 2020 (inclusive). The number of AKI patients, including patients who required/did not require renal replacement therapy (RRT), and deceased patients with AKI/severe AKI, who received different types of ECMO were collated and analyzed using STATA. Results The results indicated that there were no significant differences in the risk of AKI/severe AKI among different types of ECMO. However, the presence of AKI and severe AKI during veno-arterial (VA) ECMO was more strongly associated with mortality. Conclusions Although mortality rates related to AKI/severe AKI during VV ECMO are high, the occurrence of AKI/severe AKI during VA ECMO should be given greater attention, as these instances are considered strong indicators of patient deterioration and even death. Additional studies are needed to corroborate these findings.

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Increased blood transfusion and its impact in patients having tracheostomy while on extracorporeal membrane oxygenation

Perfusion ◽

10.1177/0267659118795390 ◽

2018 ◽

Vol 34 (2) ◽

pp. 143-146 ◽

Cited By ~ 2

Author(s):

Dwight D. Harris ◽

Alexis E. Shafii ◽

Maher Baz ◽

Thomas A. Tribble ◽

Victor A. Ferraris

Keyword(s):

Blood Loss ◽

Extracorporeal Membrane Oxygenation ◽

Blood Products ◽

Inclusion Criteria ◽

Total Blood ◽

Membrane Oxygenation ◽

Venovenous Extracorporeal Membrane Oxygenation ◽

The Impact ◽

Complications And Mortality ◽

Vv Ecmo

Introduction: Tracheostomy has been utilized in combination with venovenous extracorporeal membrane oxygenation (VV-ECMO) to enable early spontaneous breathing and minimize sedation requirements. Tracheostomy has been previously reported to be safe in patients supported on VV-ECMO; however, the impact of tracheostomy on blood loss in VV-ECMO patients is unknown. Methods: We analyzed VV-ECMO patients with and without tracheostomy over a 5-year period. In order to avoid other potential sources of blood loss not related to tracheostomy or ECMO-related blood loss, patients who underwent a recent surgery prior to ECMO or during ECMO (other than tracheostomy) were excluded. Results: Sixty-three patients meeting the inclusion criteria were identified (tracheostomy n=30, non-tracheostomy n=33). Tracheostomy patients were found to require more daily transfusions of red blood cells (RBC) (0.47 [0.20-1.0] vs. 0.23 [0.06-0.40] units/day, p=0.02) and total blood products (0.60 [0.32-1.0] vs. 0.31 [0.10-0.50] units/day, p=0.01). Conclusions: These results suggest that tracheostomy while on VV-ECMO predisposes patients to increased transfusion burden. Based on previous research, this increased transfusion burden could potentially be linked to increased complications and mortality.

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Early and Long-Term Outcomes after Direct Bridge-to-Transplantation with Extracorporeal Membrane Oxygenation

The Heart Surgery Forum ◽

10.1532/hsf.3861 ◽

2021 ◽

Vol 24 (6) ◽

pp. E1033-E1042

Author(s):

Mélanie Hébert ◽

Pierre-Emmanuel Noly ◽

Yoan Lamarche ◽

Ismail Bouhout ◽

Marion Mauduit ◽

...

Keyword(s):

Overall Survival ◽

Extracorporeal Membrane Oxygenation ◽

Kidney Injury ◽

Patient Characteristics ◽

Ecmo Support ◽

Bridge To Transplantation ◽

Long Term Outcomes ◽

Membrane Oxygenation ◽

Va Ecmo

Background: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as direct bridge-to-transplantation (dBTT) remains controversial. We compared the short- and long-term outcomes of adult patients undergoing urgent heart transplantation (HT) with (dBTT) and without (non-BTT) VA-ECMO support at the time of HT. Methods: Adults who underwent urgent HT in two institutions were assessed (N = 133; dBTT: N = 34 and non-BTT: N = 99). Patient characteristics, donor characteristics, in-hospital outcomes, and overall survival were compared. Mean follow up was 77±38 months and was 100% complete. Mortality predictors were identified using univariate and multivariate analyses. Results: Before HT, patients with dBTT had higher rates of ischemic cardiomyopathy, acute kidney injury, liver failure, respiratory failure, and longer graft ischemia times. More patients in the dBTT group had complications, such as requiring VA-ECMO postoperatively (dBTT=50% vs. non-BTT=20%, P < 0.01). Hospital deaths (dBTT=23% vs. non-BTT=19%, P = 0.58), one-year (74% vs. 80%) and five-year survival (62% vs. 75%, P = 0.74 for overall survival) were not significantly different. The MELD-XI score and previous cardiac surgery were independent predictors of hospital mortality. Conclusion: Direct bridge-to-transplantation in patients on VA-ECMO support was not associated with worse long-term outcomes compared with non-VA-ECMO urgent HT, especially in recipients without any associated organ failure and a low MELD-XI score before HT.

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