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Lai A, Omori N, Napolitano JE, Antaki JF, Cook KE. Effect of Artificial Lung Fiber Bundle Geometric Design on Micro- and Macro-scale Clot Formation. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.05.574443. [PMID: 38260509 PMCID: PMC10802461 DOI: 10.1101/2024.01.05.574443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
The hollow fiber membrane bundle is the functional component of artificial lungs, transferring oxygen and carbon dioxide to and from the blood. It is also the primary location of blood clot formation and propagation in these devices. The geometric design of fiber bundles is defined by a narrow range of parameters that determine gas exchange efficiency and blood flow resistance, such as fiber packing density, path length, and frontal area. However, these parameters also affect thrombosis. This study investigated the effect of these parameters on clot formation using 3-D printed flow chambers that mimic the geometry and blood flow patterns of fiber bundles. Hollow fibers were represented by an array of vertical micro-rods (380 micron diameter) arranged with varying packing densities (40, 50, and 60%) and path lengths (2 and 4 cm). Blood was pumped through the device corresponding to three mean blood flow velocities (16, 20, and 25 cm/min). Results showed that (1) clot formation decreases dramatically with decreasing packing density and increasing blood flow velocity, (2) clot formation at the outlet of fiber bundle enhances deposition upstream, and consequently (3) greater path length provides more clot-free fiber surface area for gas exchange than a shorter path length. These results can be used to create less thrombogenic, more efficient artificial lung designs. Translational Impact Sentence Fiber bundle parameters, such as decreased packing density, increased blood flow velocity, and a longer path length, can be used to design a less thrombogenic, more efficient artificial lung to extend functionality.
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Ikeda T, Ichiba S, Sasaki T, Sato M, Konoeda C, Okamoto T, Miyazaki Y, Nakajima J, Sakamoto A. A case of severe respiratory failure due to interstitial pneumonia successfully bridged to lung transplantation from a brain-dead donor using 109-day veno-arterial extracorporeal membrane oxygenation. J Artif Organs 2023; 26:84-88. [PMID: 35731429 DOI: 10.1007/s10047-022-01341-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 05/24/2022] [Indexed: 10/17/2022]
Abstract
In Japan, successful cases of a bridge to lung transplantation (BTT) by extracorporeal membrane oxygenation (ECMO) are rare. We present the case of a man in his thirties, diagnosed with interstitial pneumonia 6 years prior and registered for lung transplant 1 year prior due to disease progression despite treatment. Due to the patient's worsening respiratory failure, he was transferred to our hospital for BTT by ECMO. Since long-term management was expected and pulmonary hypertension was present, veno-arterial (V-A) ECMO was conducted using the right atrial blood outflow via the right internal jugular vein and right axillary artery inflow via a vascular graft. After tracheostomy, he was managed as "Awake ECMO". In addition, interprofessional collaboration such as physiotherapist rehabilitation, nurses, and liaison teams prevented muscle weakness and supported the mental aspect. We were able to minimize complications such as severe infections and bleeding. A compatible brain-dead donor was found on day 108 after introducing ECMO, and the patient was transferred to a transplant facility on day 109. The peripheral upper V-A ECMO is one of the configurations suitable for long-term BTT management.
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Affiliation(s)
- Tokuji Ikeda
- Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan.
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.
| | - Shingo Ichiba
- Department of Surgical Intensive Care Medicine, Nippon Medical School Hospital, Tokyo, Japan.
- Department of Anesthesiology, Nippon Medical School, Tokyo, Japan.
| | - Takashi Sasaki
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Chihiro Konoeda
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Tsukasa Okamoto
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasunari Miyazaki
- Department of Respiratory Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Jun Nakajima
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo, Japan
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Stokes JW, Gannon WD, Bacchetta M. Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant. Semin Respir Crit Care Med 2021; 42:380-391. [PMID: 34030201 DOI: 10.1055/s-0041-1728795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Extracorporeal 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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Affiliation(s)
- John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Whitney D Gannon
- Departments of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee
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4
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Naito N, Ukita R, Wilbs J, Wu K, Lin X, Carleton NM, Roberts K, Jiang S, Heinis C, Cook KE. Combination of polycarboxybetaine coating and factor XII inhibitor reduces clot formation while preserving normal tissue coagulation during extracorporeal life support. Biomaterials 2021; 272:120778. [PMID: 33812214 DOI: 10.1016/j.biomaterials.2021.120778] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 03/16/2021] [Accepted: 03/20/2021] [Indexed: 12/17/2022]
Abstract
Blood contact with high surface area medical devices, such as dialysis and extracorporeal life support (ECLS), induces rapid surface coagulation. Systemic anticoagulation, such as heparin, is thus necessary to slow clot formation, but some patients suffer from bleeding complications. Both problems might be reduced by 1) replacing heparin anticoagulation with artificial surface inhibition of the protein adsorption that initiates coagulation and 2) selective inhibition of the intrinsic branch of the coagulation cascade. This approach was evaluated by comparing clot formation and bleeding times during short-term ECLS using zwitterionic polycarboxybetaine (PCB) surface coatings combined with either a potent, selective, bicyclic peptide inhibitor of activated Factor XII (FXII900) or standard heparin anticoagulation. Rabbits underwent venovenous ECLS with small sham oxygenators for 60 min using three means of anticoagulation (n = 4 ea): (1) PCB coating + FXII900 infusion, (2) PCB coating + heparin infusion with an activated clotting time of 220-300s, and (3) heparin infusion alone. Sham oxygenator blood clot weights in the PCB + FXII900 and PCB + heparin groups were 4% and 25% of that in the heparin group (p < 10-6 and p < 10-5), respectively. At the same time, the bleeding time remained normal in the PCB + FXII900 group (2.4 ± 0.2 min) but increased to 4.8 ± 0.5 and 5.1 ± 0.7 min in the PCB + heparin and heparin alone groups (p < 10-4 and 0.01). Sham oxygenator blood flow resistance was significantly lower in the PCB + FXII900 and PCB + heparin groups than in the heparin only group (p < 10-6 and 10-5). These results were confirmed by gross and scanning electron microscopy (SEM) images and fibrinopeptide A (FPA) concentrations. Thus, the combined use of PCB coating and FXII900 markedly reduced sham oxygenator coagulation and tissue bleeding times versus the clinical standard of heparin anticoagulation and is a promising anticoagulation method for clinical ECLS.
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Affiliation(s)
- Noritsugu Naito
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Rei Ukita
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Jonas Wilbs
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Kan Wu
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Xiaojie Lin
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Neil M Carleton
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Kalliope Roberts
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Shaoyi Jiang
- Department of Chemical Engineering, University of Washington, Seattle, WA, USA
| | - Christian Heinis
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Keith E Cook
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA.
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Staudinger T. Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications. Perfusion 2020; 35:492-508. [PMID: 32156179 DOI: 10.1177/0267659120906048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
TECHNOLOGY Extracorporeal carbon dioxide removal means the removal of carbon dioxide from the blood across a gas exchange membrane without substantially improving oxygenation. Carbon dioxide removal is possible with substantially less extracorporeal blood flow than needed for oxygenation. Techniques for extracorporeal carbon dioxide removal include (1) pumpless arterio-venous circuits, (2) low-flow venovenous circuits based on the technology of continuous renal replacement therapy, and (3) venovenous circuits based on extracorporeal membrane oxygenation technology. INDICATIONS Extracorporeal carbon dioxide removal has been shown to enable more protective ventilation in acute respiratory distress syndrome patients, even beyond the so-called "protective" level. Although experimental data suggest a benefit on ventilator induced lung injury, no hard clinical evidence with respect to improved outcome exists. In addition, extracorporeal carbon dioxide removal is a tool to avoid intubation and mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease failing non-invasive ventilation. This concept has been shown to be effective in 56-90% of patients. Extracorporeal carbon dioxide removal has also been used in ventilated patients with hypercapnic respiratory failure to correct acidosis, unload respiratory muscle burden, and facilitate weaning. In patients suffering from terminal fibrosis awaiting lung transplantation, extracorporeal carbon dioxide removal is able to correct acidosis and enable spontaneous breathing during bridging. Keeping these patients awake, ambulatory, and breathing spontaneously is associated with favorable outcome. COMPLICATIONS Complications of extracorporeal carbon dioxide removal are mostly associated with vascular access and deranged hemostasis leading to bleeding. Although the spectrum of complications may differ, no technology offers advantages with respect to rate and severity of complications. So called "high-extraction systems" working with higher blood flows and larger membranes may be more effective with respect to clinical goals.
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Affiliation(s)
- Thomas Staudinger
- Department of Medicine I, Intensive Care Unit, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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Yeo HJ, Son J, Lee SG, Son BS, Cho WH, Kim TH, Kim JS, Je HG, Kim DH. Clinical Result and Feasibility of Transport ECMO in Thoracic Transplantation. Transplant Proc 2020; 51:3385-3390. [PMID: 31810506 DOI: 10.1016/j.transproceed.2019.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 05/15/2019] [Accepted: 06/05/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION There is an increasing need for transport extracorporeal membrane oxygenation (ECMO) in thoracic transplantation. This study was performed to evaluate the safety and feasibility of transport ECMO in thoracic transplantation. PATIENTS AND METHODS A total of 24 patients referred from outside hospitals for ECMO treatment used our interhospital ECMO transport system from December 2011 to October 2018. We retrospectively analyzed the clinical data to evaluate the feasibility and safety of transport ECMO for thoracic transplantations. RESULTS The median transport distance was 34 km (interquartile range [IQR]: 29-45) and the median transport time was 38 minutes (IQR: 26-45). There were no adverse events during transit in any patient. ECMO weaning was possible in 19 patients (79%) and 13 patients (54%) were weaned from mechanical ventilation. Of these patients, only 14 (58%) underwent transplantation, of whom 8 received lung transplants (53%) and 6 received heart transplants (67%). Among the patients receiving transplants, intensive care unit discharge was possible in 9 patients (64%), and 8 patients (57%) were discharged home. CONCLUSIONS Transport ECMO to the transplantation center is a useful strategy to rescue patients with cardiorespiratory failure who may require transplantation, providing an additional means of improving the chance of survival.
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Affiliation(s)
- Hye Ju Yeo
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Joohyung Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Sang Gwon Lee
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Bong Soo Son
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Woo Hyun Cho
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Tae Hwa Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jeong Su Kim
- Department of Internal Medicine, Division of cardiology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Hyung Gon Je
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Do Hyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Yangsan, South Korea.
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Comber EM, Palchesko RN, Ng WH, Ren X, Cook KE. De novo lung biofabrication: clinical need, construction methods, and design strategy. Transl Res 2019; 211:1-18. [PMID: 31103468 DOI: 10.1016/j.trsl.2019.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/10/2019] [Accepted: 04/25/2019] [Indexed: 01/22/2023]
Abstract
Chronic lung disease is the 4th leading cause of death in the United States. Due to a shortage of donor lungs, alternative approaches to support failing, native lungs have been attempted, including mechanical ventilation and various forms of artificial lungs. However, each of these support methods causes significant complications when used for longer than a few days and are thus not capable of long-term support. For artificial lungs, complications arise due to interactions between the artificial materials of the device and the blood of the recipient. A potential new approach is the fabrication of lungs from biological materials, such that the gas exchange membranes provide a more biomimetic blood-contacting interface. Recent advancements with three-dimensional, soft-tissue biofabrication methods and the engineering of thin, basement membranes demonstrate the potential of fabricating a lung scaffold from extracellular matrix materials. This scaffold could then be seeded with endothelial and epithelial cells, matured within a bioreactor, and transplanted. In theory, this fully biological lung could provide improved, long-term biocompatibility relative to artificial lungs, but significant work is needed to perfect the organ design and construction methods. Like artificial lungs, biofabricated lungs do not need to follow the shape and structure of a native lung, allowing for simpler manufacture. However, various functional requirements must still be met, including stable, efficient gas exchange for a period of years. Design decisions depend on the disease state, how the organ is implanted, and the latest biofabrication methods available in a rapidly evolving field.
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Affiliation(s)
- Erica M Comber
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania.
| | - Rachelle N Palchesko
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Wai Hoe Ng
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Xi Ren
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Keith E Cook
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, Pennsylvania
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8
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Ukita R, Wu K, Lin X, Carleton NM, Naito N, Lai A, Do-Nguyen CC, Demarest CT, Jiang S, Cook KE. Zwitterionic poly-carboxybetaine coating reduces artificial lung thrombosis in sheep and rabbits. Acta Biomater 2019; 92:71-81. [PMID: 31082571 PMCID: PMC6633914 DOI: 10.1016/j.actbio.2019.05.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/30/2019] [Accepted: 05/07/2019] [Indexed: 12/24/2022]
Abstract
Current artificial lungs fail in 1-4 weeks due to surface-induced thrombosis. Biomaterial coatings may be applied to anticoagulate artificial surfaces, but none have shown marked long-term effectiveness. Poly-carboxybetaine (pCB) coatings have shown promising results in reducing protein and platelet-fouling in vitro. However, in vivo hemocompatibility remains to be investigated. Thus, three different pCB-grafting approaches to artificial lung surfaces were first investigated: 1) graft-to approach using 3,4-dihydroxyphenylalanine (DOPA) conjugated with pCB (DOPA-pCB); 2) graft-from approach using the Activators ReGenerated by Electron Transfer method of atom transfer radical polymerization (ARGET-ATRP); and 3) graft-to approach using pCB randomly copolymerized with hydrophobic moieties. One device coated with each of these methods and one uncoated device were attached in parallel within a veno-venous sheep extracorporeal circuit with no continuous anticoagulation (N = 5 circuits). The DOPA-pCB approach showed the least increase in blood flow resistance and the lowest incidence of device failure over 36-hours. Next, we further investigated the impact of tip-to-tip DOPA-pCB coating in a 4-hour rabbit study with veno-venous micro-artificial lung circuit at a higher activated clotting time of 220-300 s (N ≥ 5). Here, DOPA-pCB reduced fibrin formation (p = 0.06) and gross thrombus formation by 59% (p < 0.05). Therefore, DOPA-pCB is a promising material for improving the anticoagulation of artificial lungs. STATEMENT OF SIGNIFICANCE: Chronic lung diseases lead to 168,000 deaths each year in America, but only 2300 lung transplantations happen each year. Hollow fiber membrane oxygenators are clinically used as artificial lungs to provide respiratory support for patients, but their long-term viability is hindered by surface-induced clot formation that leads to premature device failure. Among different coatings investigated for blood-contacting applications, poly-carboxybetaine (pCB) coatings have shown remarkable reduction in protein adsorption in vitro. However, their efficacy in vivo remains unclear. This is the first work that investigates various pCB-coating methods on artificial lung surfaces and their biocompatibility in sheep and rabbit studies. This work highlights the promise of applying pCB coatings on artificial lungs to extend its durability and enable long-term respiratory support for lung disease patients.
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Affiliation(s)
- Rei Ukita
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA.
| | - Kan Wu
- Department of Chemical Engineering, University of Washington, Box 351750, Seattle, WA 98195-1750, USA
| | - Xiaojie Lin
- Department of Chemical Engineering, University of Washington, Box 351750, Seattle, WA 98195-1750, USA
| | - Neil M Carleton
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Noritsugu Naito
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Angela Lai
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Chi Chi Do-Nguyen
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Caitlin T Demarest
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
| | - Shaoyi Jiang
- Department of Chemical Engineering, University of Washington, Box 351750, Seattle, WA 98195-1750, USA
| | - Keith E Cook
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Scott Hall 4(th) Floor, Pittsburgh, PA 15213, USA
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9
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72-Hour in vivo evaluation of nitric oxide generating artificial lung gas exchange fibers in sheep. Acta Biomater 2019; 90:122-131. [PMID: 30953800 DOI: 10.1016/j.actbio.2019.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 03/26/2019] [Accepted: 04/02/2019] [Indexed: 12/21/2022]
Abstract
The large, densely packed artificial surface area of artificial lungs results in rapid clotting and device failure. Surface generated nitric oxide (NO) can be used to reduce platelet activation and coagulation on gas exchange fibers, while not inducing patient bleeding due to its short half-life in blood. To generate NO, artificial lungs can be manufactured with PDMS hollow fibers embedded with copper nanoparticles (Cu NP) and supplied with an infusion of the NO donor S-nitroso-N-acetyl-penicillamine (SNAP). The SNAP reacts with Cu NP to generate NO. This study investigates clot formation and gas exchange performance of artificial lungs with either NO-generating Cu-PDMS or standard polymethylpentene (PMP) fibers. One miniature artificial lung (MAL) made with 10 wt% Cu-PDMS hollow fibers and one PMP control MAL were attached to sheep in parallel in a veno-venous extracorporeal membrane oxygenation circuit (n = 8). Blood flow through each device was set at 300 mL/min, and each device received a SNAP infusion of 0.12 μmol/min. The ACT was between 110 and 180 s in all cases. Blood flow resistance was calculated as a measure of clot formation on the fiber bundle. Gas exchange experiments comparing the two groups were conducted every 24 h at blood flow rates of 300 and 600 mL/min. Devices were removed once the resistance reached 3x baseline (failure) or following 72 h. All devices were imaged using scanning electron microscopy (SEM) at the inlet, outlet, and middle of the fiber bundle. The Cu-PDMS NO generating MALs had a significantly smaller increase in resistance compared to the control devices. Resistance rose from 26 ± 8 and 23 ± 5 in the control and Cu-PDMS devices, respectively, to 35 ± 8 mmHg/(mL/min) and 72 ± 23 mmHg/(mL/min) at the end of each experiment. The resistance and SEM imaging of fiber surfaces demonstrate lower clot formation on Cu-PDMS fibers. Although not statistically significant, oxygen transfer for the Cu-PDMS MALs was 13.3% less than the control at 600 mL/min blood flow rate. Future in vivo studies with larger Cu-PDMS devices are needed to define gas exchange capabilities and anticoagulant activity over a long-term study at clinically relevant ACTs. STATEMENT OF SIGNIFICANCE: In artificial lungs, the large, densely-packed blood contacting surface area of the hollow fiber bundle is critical for gas exchange but also creates rapid, surface-generated clot requiring significant anticoagulation. Monitoring of anticoagulation, thrombosis, and resultant complications has kept permanent respiratory support from becoming a clinical reality. In this study, we use a hollow fiber material that generates nitric oxide (NO) to prevent platelet activation at the blood contacting surface. This material is tested in vivo in a miniature artificial lung and compared against the clinical standard. Results indicated significantly reduced clot formation. Surface-focused anticoagulation like this should reduce complication rates and allow for permanent respiratory support by extending the functional lifespan of artificial lungs and can further be applied to other medical devices.
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10
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Mulligan MS, Weill D, Davis RD, Christie JD, Farjah F, Singer JP, Hartwig M, Sanchez PG, Kreisel D, Ware LB, Bermudez C, Hachem RR, Weyant MJ, Gries C, Awori Hayanga JW, Griffith BP, Snyder LD, Odim J, Craig JM, Aggarwal NR, Reineck LA. National Heart, Lung, and Blood Institute and American Association for Thoracic Surgery Workshop Report: Identifying collaborative clinical research priorities in lung transplantation. J Thorac Cardiovasc Surg 2018; 156:2355-2365. [PMID: 30244865 PMCID: PMC7333918 DOI: 10.1016/j.jtcvs.2018.08.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/01/2018] [Accepted: 08/05/2018] [Indexed: 12/15/2022]
Abstract
This report summarizes the discussion and recommendations from the June 2017 NHLBI-AATS Workshop on Identifying Collaborative Clinical Research Priorities in Lung Transplantation.
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Affiliation(s)
- Michael S Mulligan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | | | | | - Jason D Christie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Farhood Farjah
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, Wash
| | - Jonathan P Singer
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, Calif
| | - Matthew Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University, St Louis, Mo
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University, St Louis, Mo
| | - Michael J Weyant
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Denver, Colo
| | | | | | - Bartley P Griffith
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, Baltimore, Md
| | - Laurie D Snyder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
| | - Jonah Odim
- Clinical Transplantation Section, National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - J Matthew Craig
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Md
| | - Neil R Aggarwal
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Md
| | - Lora A Reineck
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, Bethesda, Md.
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11
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Merkle J, Djorjevic I, Sabashnikov A, Kuhn EW, Deppe AC, Eghbalzadeh K, Fattulayev J, Hohmann C, Zeriouh M, Kuhn-Régnier F, Choi YH, Mader N, Wahlers T. Mobile ECMO – A divine technology or bridge to nowhere? Expert Rev Med Devices 2017; 14:821-831. [DOI: 10.1080/17434440.2017.1376583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djorjevic
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Elmar W Kuhn
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Javid Fattulayev
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Christopher Hohmann
- Department of Cardiology, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Ferdinand Kuhn-Régnier
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Navid Mader
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Cologne, Germany
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Hayes D, Tobias JD, Tumin D. Center Volume and Extracorporeal Membrane Oxygenation Support at Lung Transplantation in the Lung Allocation Score Era. Am J Respir Crit Care Med 2017; 194:317-26. [PMID: 26840155 DOI: 10.1164/rccm.201511-2222oc] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Outcomes related to extracorporeal membrane oxygenation (ECMO) used to bridge patients to lung transplantation in the context of center differences in transplant expertise have not been investigated. OBJECTIVES To determine the effects of ECMO at time of transplant on survival in adult patients who underwent transplant surgery in historically low- and high-volume centers. METHODS The United Network for Organ Sharing database was used to classify centers according to transplant volume between May 2005 and May 2010 as low-volume centers (bottom 50% of centers), medium-volume centers (next 25%), or high-volume centers (top 25%). Influences of ECMO on post-transplant survival were estimated among adults receiving lung transplants between June 2010 and June 2015 based on historic center volume in the preceding 5 years. MEASUREMENTS AND MAIN RESULTS Sixty-five centers were classified according to lung transplant volume in 2005-2010, with 8,228 adults (279 on ECMO) who underwent transplants at these centers between June 2010 and June 2015 included in the survival analysis. In multivariable Cox analysis stratified by center, we found that, in historically low-volume centers, ECMO was associated with increased post-transplant mortality hazard (hazard ratio, 1.968; 95% confidence interval, 1.083-3.577; P = 0.026). In contrast, in historically high-volume centers, ECMO had no adverse influence on post-transplant survival (hazard ratio, 0.853; 95% confidence interval, 0.596-1.222; P = 0.386). CONCLUSIONS An adverse effect of ECMO at the time of lung transplant was evident in low-volume centers but absent in centers with experience of performing more than 170 lung transplants in the first 5 years of the lung allocation score era.
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Affiliation(s)
- Don Hayes
- 1 Department of Pediatrics.,2 Department of Internal Medicine.,3 Department of Surgery, and.,4 Center for Epidemiology of Organ Failure and Transplantation.,5 Section of Pulmonary Medicine, and
| | - Joseph D Tobias
- 6 Department of Anesthesiology, The Ohio State University, Columbus, Ohio; and.,7 Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Dmitry Tumin
- 1 Department of Pediatrics.,7 Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Kearns SK, Hernandez OO. "Awake" Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant. AACN Adv Crit Care 2016; 27:293-300. [PMID: 27959313 DOI: 10.4037/aacnacc2016792] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Mortality of patients awaiting lung transplant remains a significant problem as the number of patients on the waiting list far surpasses the number of donor organs available. Interest in the use of "awake" extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant has emerged because this strategy offers several benefits over mechanical ventilation. This article provides a review of relevant literature and discusses indications and complications of awake ECMO therapy, cannulation strategies, and nursing considerations for this patient population.
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Affiliation(s)
- Sara K Kearns
- Sara K. Kearns is ECMO Specialist, Baylor University Medical Center, 3500 Gaston Ave, Dallas, TX 75246 . Omar O. Hernandez is ECMO Specialist, Baylor University Medical Center, Dallas, Texas
| | - Omar O Hernandez
- Sara K. Kearns is ECMO Specialist, Baylor University Medical Center, 3500 Gaston Ave, Dallas, TX 75246 . Omar O. Hernandez is ECMO Specialist, Baylor University Medical Center, Dallas, Texas
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14
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Hayanga JWA, Aboagye JK, Hayanga HK, Luketich JD, D'Cunha J. Extracorporeal membrane oxygenation as a bridge to lung re-transplantation: Is there a role? J Heart Lung Transplant 2016; 35:901-5. [PMID: 27435530 DOI: 10.1016/j.healun.2016.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND In this study we sought to determine survival rates after use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung re-transplantation (re-LT). METHODS Propensity-adjusted analysis was performed on data from the Scientific Registry of Transplant Recipients (SRTR) to evaluate survival in recipients between the years 1988 and 2012, based on the use of ECMO before re-LT. RESULTS A total of 854 adult re-LT recipients were identified. Extracorporeal support had been used as a bridge in 55 (6.8%) of the recipients, whereas 799 (93.2%) had undergone re-LT without the use of ECMO. Compared with non-ECMO patients, the ECMO patients were more likely to have: higher body mass index (p = 0.003); received lungs from an older donor (p = 0.04); higher total bilirubin (p = 0.002); undergone bilateral lung transplantation (p = 0.01); diabetes (p = 0.04); mechanical ventilation (p < 0.0005); and been hospitalized in the intensive care unit (p < 0.0001). They were also more likely to have a diagnosis of bronchiolitis obliterans syndrome (p < 0.0001), be on inhaled nitric oxide (p < 0.0001), and have a shorter waitlist time before re-LT (p < 0.0001). Compared with the non-ECMO group, 30-day survival for the ECMO group was lower (67.3% vs 91.2%, p = 0.0002). Obesity was identified as a predictor of increased mortality in re-LT hazard ratio 2.97 (1.18 to 7.50), p = 0.02. CONCLUSION This contemporary analysis of survival after use of ECMO as a bridge to re-LT revealed lower survival in the ECMO group.
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Affiliation(s)
- J W Awori Hayanga
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Jonathan K Aboagye
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Heather K Hayanga
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Raleigh L, Ha R, Hill C. Extracorporeal Membrane Oxygenation Applications in Cardiac Critical Care. Semin Cardiothorac Vasc Anesth 2015; 19:342-52. [PMID: 26403786 DOI: 10.1177/1089253215607065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The use of extracorporeal membrane oxygenation therapy (ECMO) in cardiac critical care has steadily increased over the past decade. Significant improvements in the technology associated with ECMO have propagated this recent resurgence and contributed to improved patient outcomes in the fields of cardiac and transplant (heart and lung) surgery. Specifically, ECMO is being increasingly utilized as a bridge to heart and lung transplantation, as well as to ventricular assist device placement. ECMO is also employed during the administration of cardiopulmonary resuscitation, known as extracorporeal life support. In this review, we examine the recent literature regarding the applications of ECMO and also describe emerging topics involving current ECMO management strategies.
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Affiliation(s)
- Lindsay Raleigh
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
| | - Rich Ha
- Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA
| | - Charles Hill
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, USA
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16
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Hayes D, Whitson BA, Black SM, Preston TJ, Papadimos TJ, Tobias JD. Influence of age on survival in adult patients on extracorporeal membrane oxygenation before lung transplantation. J Heart Lung Transplant 2015; 34:832-8. [DOI: 10.1016/j.healun.2014.12.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/24/2014] [Accepted: 12/17/2014] [Indexed: 11/30/2022] Open
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17
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Hayes D, McConnell PI, Tobias JD, Whitson BA, Preston TJ, Yates AR, Galantowicz M. Survival in children on extracorporeal membrane oxygenation at the time of lung transplantation. Pediatr Transplant 2015; 19:87-93. [PMID: 25425268 DOI: 10.1111/petr.12400] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2014] [Indexed: 11/29/2022]
Abstract
Limited data exist on ECMO at the time of LTx in children. The UNOS database was queried from 2000 to 2013 for pediatric lung transplant recipients (<18 yr) to assess post-transplant survival of patients on ECMO at the time of LTx. Of 587 pediatric recipients with 17 on ECMO, 585 were used for univariate and Kaplan-Meier function analysis, 535 for multivariate Cox models, and 24 for propensity score matching. Univariate Cox (HR = 1.777; 95% CI: 0.658, 4.803; p = 0.257) and Kaplan-Meier function (log-rank test: chi-square (df = 1): 1.32, p = 0.250) analyses did not identify a survival difference between ECMO and non-ECMO, while multivariate Cox models (HR = 1.821; 95% CI: 0.654, 5.065; p = 0.251) did not demonstrate an increased risk for death. Propensity score matching analysis (HR = 1.500; 95% CI: 0.251, 8.977; p = 0.657) also failed to demonstrate a significantly increased hazard ratio. Using a contemporary cohort of pediatric lung transplant recipients, the use of ECMO at the time of lung transplantation did not negatively impact survival.
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Affiliation(s)
- Don Hayes
- Department of Pediatrics, The Ohio State University, Columbus, OH, USA; Department of Internal Medicine, The Ohio State University, Columbus, OH, USA; Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Schellongowski P, Riss K, Staudinger T, Ullrich R, Krenn CG, Sitzwohl C, Bojic A, Wohlfarth P, Sperr WR, Rabitsch W, Aigner C, Taghavi S, Jaksch P, Klepetko W, Lang G. Extracorporeal CO2 removal as bridge to lung transplantation in life-threatening hypercapnia. Transpl Int 2014; 28:297-304. [PMID: 25387861 DOI: 10.1111/tri.12486] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/18/2014] [Accepted: 11/06/2014] [Indexed: 12/12/2022]
Abstract
In patients awaiting lung transplantation (LTX), adequate gas exchange may not be sufficiently achieved by mechanical ventilation alone if acute respiratory decompensation arises. We report on 20 patients with life-threatening hypercapnia who received extracorporeal CO2 removal (ECCO2-R) by means of the interventional lung assist (ILA®, Novalung) as bridge to LTX. The most common underlying diagnoses were bronchiolitis obliterans syndrome, cystic fibrosis, and idiopathic pulmonary fibrosis, respectively. The type of ILA was pumpless arteriovenous or pump-driven venovenous (ILA activve®, Novalung) in 10 patients each. ILA bridging was initiated in 15 invasively ventilated and five noninvasively ventilated patients, of whom one had to be intubated prior to LTX. Hypercapnia and acidosis were effectively corrected in all patients within the first 12 h of ILA therapy: PaCO2 declined from 109 (70-146) to 57 (45-64) mmHg, P < 0.0001; pH increased from 7.20 (7.06-7.28) to 7.39 (7.35-7.49), P < 0.0001. Four patients were switched to extracorporeal membrane oxygenation due to progressive hypoxia or circulatory failure. Nineteen patients (95%) were successfully transplanted. Hospital and 1-year survival was 75 and 72%, respectively. Bridging to LTX with ECCO2-R delivered by arteriovenous pumpless or venovenous pump-driven ILA is feasible and associated with high transplantation and survival rates.
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Affiliation(s)
- Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria
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19
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Extubation and extracorporeal membrane oxygenation: what a difference a decade makes!! Pediatr Crit Care Med 2014; 15:907-9. [PMID: 25370061 DOI: 10.1097/pcc.0000000000000265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Hayanga AJ, Aboagye J, Esper S, Shigemura N, Bermudez CA, D'Cunha J, Bhama JK. Extracorporeal membrane oxygenation as a bridge to lung transplantation in the United States: an evolving strategy in the management of rapidly advancing pulmonary disease. J Thorac Cardiovasc Surg 2014; 149:291-6. [PMID: 25524684 DOI: 10.1016/j.jtcvs.2014.08.072] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 08/13/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Improvements in technology have led to a resurgence in the use of extracorporeal membrane oxygenation as a bridge to lung transplantation. By using a national registry, we sought to evaluate how short-term survival has evolved using this strategy. METHODS With the use of the United Network for Organ Sharing database, we analyzed data from 12,458 adults who underwent lung transplantation between 2000 and 2011. Patients were categorized into 2 cohorts: 119 patients who were bridged to transplantation using extracorporeal membrane oxygenation and 12,339 patients who were not. The study period was divided into four 3-year intervals: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. With Kaplan-Meier analysis, 1-year survival was compared for the 2 cohorts of patients in each of the time periods. A propensity score-adjusted Cox regression model was used to estimate the risk of 1-year mortality. RESULTS Of the total number of recipients, 4 (3.4%) were bridged between 2000 and 2002, 17 (14.3%) were bridged between 2003 and 2005, 31 (26.1%) were bridged between 2006 and 2008, and 67 were bridged (56.3%) between 2009 and 2011. Recipients bridged using extracorporeal membrane oxygenation were more likely to be younger and diabetic and to have higher serum creatinine and bilirubin levels. The 1-year survival for those bridged with extracorporeal membrane oxygenation was significantly lower in subsequent periods: 25.0% versus 81.0% (2000-2002), 47.1% versus 84.2% (2006-2008), and 74.4% versus 85.7% (2009-2011). However, this survival progressively increased with each period, as did the number of patients bridged using extracorporeal membrane oxygenation. CONCLUSIONS Short-term survival with the use of extracorporeal membrane oxygenation as a bridge to lung transplantation has significantly improved over the past few years.
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Affiliation(s)
- Awori J Hayanga
- DeVos Heart and Lung Transplantation Program Spectrum Health, Michigan State University, Grand Rapids, Mich
| | | | - Stephen Esper
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Christian A Bermudez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jay K Bhama
- Heart and Vascular Center, Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
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Ventetuolo CE, Muratore CS. Extracorporeal life support in critically ill adults. Am J Respir Crit Care Med 2014; 190:497-508. [PMID: 25046529 PMCID: PMC4214087 DOI: 10.1164/rccm.201404-0736ci] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/13/2014] [Indexed: 12/18/2022] Open
Abstract
Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.
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Affiliation(s)
- Corey E. Ventetuolo
- Division of Pulmonary, Critical Care, and Sleep, Rhode Island Hospital, Departments of Medicine and Health Services, Policy, and Practice, and
| | - Christopher S. Muratore
- Division of Pediatric Surgery, Hasbro Children’s Hospital, Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
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22
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Gulack BC, Hirji SA, Hartwig MG. Bridge to lung transplantation and rescue post-transplant: the expanding role of extracorporeal membrane oxygenation. J Thorac Dis 2014; 6:1070-9. [PMID: 25132974 DOI: 10.3978/j.issn.2072-1439.2014.06.04] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 05/09/2014] [Indexed: 12/23/2022]
Abstract
Over the last several decades, the growth of lung transplantation has been hindered by a much higher demand for donor lungs than can be supplied, leading to considerable waiting time and mortality among patients waiting for transplant. This has led to the search for an alternative bridging strategy in patients with end-stage lung disease. The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation as well as a rescue strategy post-transplant for primary graft dysfunction (PGD) has been studied previously, however due to initially poor outcomes, its use was not heavily instituted. In recent years, with significant improvement in technologies, several single and multi-center studies have shown promising outcomes related to the use of ECMO as a bridging strategy as well as a therapy for patients suffering from PGD post-transplant. These results have challenged our current notion on ECMO use and hence forced us to reexamine the utility, efficacy and safety of ECMO in conjunction with lung transplantation. Through this review, we will address the various aspects related to ECMO use as a bridge to lung transplantation as well as a rescue post-transplant in the treatment of PGD. We will emphasize newer technologies related to ECMO use, examine recent observational studies and randomized trials of ECMO use before and after lung transplantation, and reflect upon our own institutional experience with the use of ECMO in these difficult clinical situations.
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Affiliation(s)
- Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sameer A Hirji
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Whitson BA, Hayes D. Indications and outcomes in adult lung transplantation. J Thorac Dis 2014; 6:1018-23. [PMID: 25132968 DOI: 10.3978/j.issn.2072-1439.2014.07.04] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 06/23/2014] [Indexed: 11/14/2022]
Abstract
Lung transplantation (LTx) is a treatment option for end-stage lung disease that would be otherwise fatal for specific patient populations. The most common indications for LTx in adults remain to be chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, alpha-1 antitrypsin deficiency, and idiopathic pulmonary arterial hypertension. Recent trends include performing re-transplantation while more patients over the age of 65 years are undergoing LTx. Even with these tendencies, slight improvements in survival have occurred. This article briefly reviews recent developments in adults undergoing LTx.
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Affiliation(s)
- Bryan A Whitson
- 1 Department of Surgery, 2 Department of Pediatrics, 3 Department of Internal Medicine, The Ohio State University, Columbus, OH, USA ; 4 Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Don Hayes
- 1 Department of Surgery, 2 Department of Pediatrics, 3 Department of Internal Medicine, The Ohio State University, Columbus, OH, USA ; 4 Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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Extracorporeal membrane oxygenation and retransplantation in lung transplantation: an analysis of the UNOS registry. Lung 2014; 192:571-6. [PMID: 24816903 DOI: 10.1007/s00408-014-9593-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/21/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite limited organ availability, extracorporeal membrane oxygenation (ECMO) and retransplantation are becoming more commonplace. METHODS Using the United Network for Organ Sharing (UNOS) database, we evaluated survival of patients treated with ECMO before lung transplantation and undergoing retransplantation. A query identified cadaveric recipients from 2001 to 2012 over the age of 6 years. RESULTS Of 15,772 lung recipients, 15 583 never received ECMO, whereas 189 did. Mean age was 52.1 ± 14.4 versus 46.8 ± 16.5 years for non-ECMO and ECMO groups, respectively (p < 0.0001). Using Kaplan-Meier method, there were survival differences between ECMO and non-ECMO groups (p < 0.0001) and first-time transplants with and without ECMO to retransplants with and without ECMO (p < 0.0001). The proportional hazards model identified higher risk with ECMO use in idiopathic pulmonary fibrosis (hazard ratio [HR] 1.09; 95 % confidence interval (CI), 1.02-1.17; p = 0.014) and retransplants (HR 1.77; 95 % CI, 1.55-2.03; p < 0.0001). CONCLUSIONS Survival for retransplantation was similar to ECMO as a primary option with significant mortality associated with ECMO use in patients with idiopathic pulmonary fibrosis and retransplants.
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Experience of extracorporeal membrane oxygenation as a bridge to lung transplantation in France. J Heart Lung Transplant 2014; 32:905-13. [PMID: 23953818 DOI: 10.1016/j.healun.2013.06.009] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 05/16/2013] [Accepted: 06/12/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is increasingly used as a bridge to lung transplantation (LTx). However, data concerning this approach remain limited. METHODS We retrospectively reviewed the medical records of all patients in France who received ECMO as a bridge to LTx from 2007 to 2011. Post-transplant survival and associated factors were assessed by the Kaplan-Meier method and the Cox model. RESULTS Included were 36 patients from 11 centers. Indications for LTx were cystic fibrosis (CF) in 20 (56%), pulmonary fibrosis (PF) in 11 (30%), and other diagnoses in 5 (14%). ECMO was venovenous for 27 patients (75%) and venoarterial for 9 (25%). Mean follow-up was 17 months. Bridging to LTx was achieved in 30 patients (83%); however, only 27 patients (75%) survived the LTx procedure, and 20 (56%) were discharged from hospital. From ECMO initiation, 2-year survival rates were 50.4% overall, 71.0% for CF patients, 27.3% for PF patients, and 20.0% for other patients (p < 0.001). From LTx, 2-year survival rates were 60.5% overall, 71.0% for CF patients, 42.9% for PF patients, and 33.0% for other patients (p = 0.04). CONCLUSIONS Our study confirms that the use of ECMO as a bridge to LTx in France could provide a medium-term survival benefit for LTx recipients with critical conditions. Survival differed by underlying respiratory disease. Larger studies are needed to further define the optimal use of ECMO.
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26
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Lee SG, Son BS, Kang PJ, Cho WH, Kim DH, Lee YS, Lee KH. The Feasibility of Extracorporeal Membrane Oxygenation Support for Inter-Hospital Transport and as a Bridge to Lung Transplantation. Ann Thorac Cardiovasc Surg 2014; 20:26-31. [DOI: 10.5761/atcs.oa.12.00203] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Casswell GK, Pilcher DV, Martin RS, Pellegrino VA, Marasco SF, Robertson C, Butt W, Buckland M, Gooi J, Snell GI, Westall GP. Buying time: The use of extracorporeal membrane oxygenation as a bridge to lung transplantation in pediatric patients. Pediatr Transplant 2013; 17:E182-8. [PMID: 24164831 DOI: 10.1111/petr.12152] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2013] [Indexed: 11/25/2022]
Abstract
To describe our experience to date of four children with end-stage lung disease who have been bridged with ECMO to successful lung transplantation in our institution. Between March 2006 and June 2012, a total of 21 pediatric patients successfully underwent lung transplantation within The Alfred's lung transplantation program. This included four children who were bridged on ECMO prior to transplantation according to the "ECMO bridge to transplant" protocol and whose clinical notes and outcomes were reviewed. Lung transplantation is an established life-saving treatment for patients with severe lung disease, but remains limited due to scarcity of suitable donor organs. This is a particular issue in the pediatric setting, where the smaller child waits disproportionately longer compared with adult patients for size-matched donor lungs. As ECMO has become more widely accepted, its use as a bridge to lung transplantation in pediatric patients with severe acute lung injury or end-stage chronic lung disease has been considered. The medical notes from the four pediatric patients were retrospectively reviewed. Our report describes excellent short- and medium-term outcomes in a small number of children who have been bridged to transplant on ECMO.
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Affiliation(s)
- Georgina K Casswell
- Lung Transplant Service, National Funded Centre for Paediatric Lung Transplantation, The Alfred Hospital, Melbourne, Vic., Australia
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28
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Hayes D, Tobias JD, Kukreja J, Preston TJ, Yates AR, Kirkby S, Whitson BA. Extracorporeal life support for acute respiratory distress syndromes. Ann Thorac Med 2013; 8:133-41. [PMID: 23922607 PMCID: PMC3731854 DOI: 10.4103/1817-1737.114290] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 10/10/2012] [Indexed: 01/21/2023] Open
Abstract
The morbidity and mortality of acute respiratory distress syndrome remain to be high. Over the last 50 years, the clinical management of these patients has undergone vast changes. Significant improvement in the care of these patients involves the development of mechanical ventilation strategies, but the benefits of these strategies remain controversial. With a growing trend of extracorporeal support for critically ill patients, we provide a historical review of extracorporeal membrane oxygenation (ECMO) including its failures and successes as well as discussing extracorporeal devices now available or nearly accessible while examining current clinical indications and trends of ECMO in respiratory failure.
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Affiliation(s)
- Don Hayes
- Section of Pulmonary Medicine, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joseph D. Tobias
- Section of Anesthesiology, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco Medical Center, San Francisco, CA, USA
| | - Thomas J. Preston
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
| | - Andrew R. Yates
- Section of Cardiology, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Stephen Kirkby
- Section of Pulmonary Medicine, Nationwide Children′s Hospital, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Section of Heart Center, Nationwide Children′s Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Bryan A. Whitson
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Odonkor PN, Stansbury L, Garcia JP, Rock P, Deshpande SP, Grigore AM. Perioperative Management of Adult Surgical Patients on Extracorporeal Membrane Oxygenation Support. J Cardiothorac Vasc Anesth 2013; 27:329-44. [DOI: 10.1053/j.jvca.2012.09.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Indexed: 12/12/2022]
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Vicente R, Moreno I, Soria A, Ramos F, Torregrosa S. Oxigenador de membrana extracorpóreo en el trasplante pulmonar. Med Intensiva 2013; 37:110-5. [DOI: 10.1016/j.medin.2012.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 06/24/2012] [Accepted: 06/28/2012] [Indexed: 10/27/2022]
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Hoopes CW, Kukreja J, Golden J, Davenport DL, Diaz-Guzman E, Zwischenberger JB. Extracorporeal membrane oxygenation as a bridge to pulmonary transplantation. J Thorac Cardiovasc Surg 2013; 145:862-7; discussion 867-8. [DOI: 10.1016/j.jtcvs.2012.12.022] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 12/07/2012] [Accepted: 12/07/2012] [Indexed: 10/27/2022]
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Pelluau S, Oualha M, Souilamas R, Hubert PH. [Respiratory failure in cystic fibrosis: management in pediatric intensive care unit, lung transplantation recommendation]. Arch Pediatr 2012; 19 Suppl 1:S40-3. [PMID: 22682491 DOI: 10.1016/s0929-693x(12)71109-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Admission to the ICU for respiratory failure of a child with cystic fibrosis is a telltale sign of the severity of the disease. Bronchopulmonary exacerbation, pneumothorax and hemoptysis are the primary causes, for which respiratory assistance is indispensable in these life-threatening situations. Non-invasive ventilation (NIV) has enabled significant progress in improving patient survival. The modalities of NIV must be tailored to both the patient and the cause of respiratory failure. Invasive ventilation, on the other hand, should be a treatment of last resort, because often associated with high mortality. It must be adapted to the therapeutic strategy involving an impending transplantation, including in critical situations where placement on a high emergency list is a possibility. Since admission to ICU is at times the reflection of the terminal evolution of the disease, ongoing treatment must hence be adapted to the comfort of the child.
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Affiliation(s)
- S Pelluau
- Service de réanimation pédiatrique et néonatale, Hôpital des Enfants, 330 avenue de Grande-Bretagne, 31026 Toulouse cedex 3, France.
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Nosotti M, Rosso L, Tosi D, Palleschi A, Mendogni P, Nataloni IF, Crotti S, Tarsia P. Extracorporeal membrane oxygenation with spontaneous breathing as a bridge to lung transplantation. Interact Cardiovasc Thorac Surg 2012; 16:55-9. [PMID: 23097371 DOI: 10.1093/icvts/ivs433] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES A large number of transplantation centres consider extracorporeal membrane oxygenation as an inappropriate option for bridging critical patients to lung transplantation. Technical improvements such as the introduction of a polymethylpentene membrane, new centrifugal pumps and heparin-coated circuits have led to a safer application of extracorporeal membrane oxygenation, and an increasing number of centres are reporting their positive experiences. The aim of this study was to review our practice in bridging critical candidates to lung transplantation with extracorporeal membrane oxygenation, by comparing patients with invasive mechanical ventilation with patients with spontaneous breathing. METHODS The records of candidates for lung transplantation treated with extracorporeal membrane oxygenation have been revised. RESULTS From February 2008 to 2012, 11 patients who experienced an abrupt worsening of their respiratory conditions were treated with extracorporeal membrane oxygenation; mean age: 33.9 ± 13.2 years, male/female ratio: 5/6, 6 patients were affected by cystic fibrosis, 2 had chronic rejection after transplantation, 2 had pulmonary fibrosis and 1 had systemic sclerosis. Seven patients were awake, while 4 patients received invasive mechanical ventilation. The sequential organ failure assessment score significantly increased during bridging time and this increase was significantly higher in the intubated patients. All the patients had bilateral lung transplantation. Spontaneously breathing patients showed a tendency to require a shorter duration of invasive mechanical ventilation, intensive care unit stay and hospital stay after transplantation. One-year survival rate was 85.7% in patients with spontaneous breathing vs 50% in patients with invasive mechanical ventilation. CONCLUSIONS Extracorporeal membrane oxygenation in spontaneously breathing patients is a feasible, effective and safe bridge to lung transplantation.
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Affiliation(s)
- Mario Nosotti
- Thoracic Surgery and Lung Transplantation Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Bridge to lung transplantation with extracorporeal membrane oxygenation support. Curr Opin Organ Transplant 2012; 17:496-502. [DOI: 10.1097/mot.0b013e328357fa4f] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Extracorporeal membrane oxygenation as a bridge to lung transplantation and recovery. J Thorac Cardiovasc Surg 2012; 144:716-21. [PMID: 22795457 DOI: 10.1016/j.jtcvs.2012.05.040] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 04/22/2012] [Accepted: 05/16/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Respiratory failure develops in many patients on lung transplant waiting lists before a suitable donor organ becomes available. Extracorporeal membrane oxygenation may be used to bridge such patients to recovery or lung transplantation. METHODS This is a review of a single-institution's experience with placing patients on extracorporeal membrane oxygenation with the intention of bridging them to lung transplantation. End points included successful bridging, duration of extracorporeal membrane oxygenation support, extubation, weaning from extracorporeal membrane oxygenation, overall survival, and extracorporeal membrane oxygenation-related complications. During an approximate 5-year period, acute respiratory failure developed in 18 patients (median age, 34 years) on the institution's lung transplant waiting list (8 hypoxemic, 9 hypercarbic, and 1 combined) who were placed on extracorporeal membrane oxygenation (13 venovenous and 5 venoarterial). RESULTS All patients achieved appropriate extracorporeal membrane oxygenation blood flow rates (median, 4.05 L/min) and good gas exchange (median, on extracorporeal membrane oxygenation partial pressure of arterial carbon dioxide 43 mm Hg and partial pressure of arterial oxygen 196 mm Hg). Thirteen patients (72%) were successfully bridged: 10 to transplant and 3 returned to baseline function. Eleven patients (61%) survived beyond 3 months, including the 10 (56%) who underwent transplantation and are still alive. The median duration of extracorporeal membrane oxygenation support for patients who underwent transplantation was 6 days (3.5-31 days) versus 13.5 days (11-19 days) for those who did not undergo transplantation (P = .45). Six patients (33%) were extubated on extracorporeal membrane oxygenation, 4 of whom underwent transplantation. Four patients (22%) who were too unstable for conventional interhospital transfer were transported on extracorporeal membrane oxygenation to Columbia University Medical Center. This subgroup had a 75% bridge to transplant or recovery rate and 100% survival in transplanted patients. CONCLUSIONS Extracorporeal membrane oxygenation is a safe and effective means of bridging well-selected patients with refractory respiratory failure to lung transplantation or return to their baseline condition.
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Bittner HB, Lehmann S, Rastan A, Garbade J, Binner C, Mohr FW, Barten MJ. Outcome of extracorporeal membrane oxygenation as a bridge to lung transplantation and graft recovery. Ann Thorac Surg 2012; 94:942-9; author reply 949-50. [PMID: 22748640 DOI: 10.1016/j.athoracsur.2012.05.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 04/27/2012] [Accepted: 05/02/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Indications for extracorporeal membrane oxygenation (ECMO) use in lung transplantation are (1) temporary assistance as a bridge to transplantation, (2) stabilization of hemodynamics during transplantation in place of cardiopulmonary bypass, and (3) treatment of severe lung dysfunction and primary graft failure after transplantation. This study compares the survival of lung transplant recipients requiring ECMO support with survival of patients without ECMO. METHODS A retrospective database review was performed for 108 consecutive patients who underwent single-lung or bilateral-lung transplantation at our center between 2002 and 2009. RESULTS Of 108 transplant recipients, 27 (25%) required venoarterial ECMO compared with 81 patients who did not. Nine patients required ECMO preoperatively (87±102 hours), and ECMO was continued for 5 patients during the lung transplant operation. Seven additional patients received ECMO during transplantation. Six patients required early (<7 days) and 5 patients delayed (≥7 days) postoperative ECMO for treatment of allograft dysfunction. The subgroup with support showed the most favorable patient discharge rate (66.7%). ECMO support was a significant risk factor for death (p<0.001). Survival was significantly reduced with the use of ECMO: 30-day, 90-day, 1-year, and 5-year survival was 97%, 91%, 83%, and 58% in the patients without ECMO compared with 63%, 44%, 33%, and 21% in those with ECMO, respectively. CONCLUSIONS Survival after lung transplantation was significantly reduced with ECMO. However, patients who survived the first year showed similar long-term survival as those patients who did not need perioperative ECMO support.
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Primary lung transplantation after bridge with extracorporeal membrane oxygenation: a plea for a shift in our paradigms for indications. Transplantation 2012; 93:729-36. [PMID: 22415051 DOI: 10.1097/tp.0b013e318246f8e1] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The introduction of the lung allocation score has brought lung transplantation (LTX) of patients on extracorporeal membrane oxygenation (ECMO) bridge into the focus of interest. We reviewed our institutional experience with ECMO as a bridge to LTX. METHODS Between 1998 and 2011, 38 patients (median age 30.1 years, range 13-66 years) underwent ECMO support with intention to bridge to primary LTX. The underlying diagnosis was cystic fibrosis (n=17), pulmonary hypertension (n=4), idiopathic pulmonary fibrosis (n=9), adult respiratory distress syndrome (n=4), hemosiderosis (n=1), bronchiolitis obliterans (n=1), sarcoidosis (n=1), and bronchiectasis (n=1). The type of extracorporeal bridge was venovenous (n=18), venoarterial (n=15), interventional lung assist (n=1), or a stepwise combination of them (n=4). The median bridging time was 5.5 days (range 1-63) days. The type of transplantation was double LTX (n=7), size-reduced double LTX (n=8), lobar LTX (n=16), split LTX (n=2), and lobar LTX after ex vivo lung perfusion (n=1). RESULTS Four patients died before transplantation. Thirty-four patients underwent LTX, of them eight patients died in the hospital after a median stay of 24.5 days (range 1-180 days). Twenty-six patients left the hospital and returned to normal life (median hospital stay=47.5 days; range 21-90 days). The 1-, 3-, and 5-year survival for all transplanted patients was 60%, 60%, and 48%, respectively. The 1-, 3-, and 5-year survival conditional on 3-month survival for patients bridged with ECMO to LTX (78%, 78%, and 63%) was not worse than for other LTX patients within the same period of time (90%, 80%, and 72%, respectively, P=0.09, 0.505, and 0.344). CONCLUSION Transplantation of patients bridged on ECMO to LTX is feasible and results in acceptable outcome.
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Expanded resources through utilization of a primary care giver extracorporeal membrane oxygenation model. Crit Care Nurs Q 2012; 35:39-49. [PMID: 22157491 DOI: 10.1097/cnq.0b013e31823b1fa1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a long-term extracorporeal support for critically ill patients with life-threatening compromises in cardiac and/or respiratory function. The unpredictability of ECMO resources for a large pediatric and adult population prompted a need for the ability to respond to significant fluctuations in the volume of patients on ECMO. Through multidisciplinary collaboration, the Primary Care Giver (PCG) ECMO Staffing Model was developed to accommodate unpredictable fluctuations in ECMO activity and to maintain flexibility and fiscal responsibility in turbulent economic times. Advancements in extracorporeal technology supported the opportunity to develop a safe and extended staffing model for ECMO. Combining the use of a centrifugal pump system with specialized and experienced cardiovascular intensive care nurses and the ECMO specialist team provided a milieu for education and training to support the new staffing model. The PCG ECMO model provides a safe, flexible, and fiscally responsible staffing model for variable ECMO activity.
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Beurtheret S, Mordant P, Paoletti X, Marijon E, Celermajer DS, Leger P, Pavie A, Combes A, Leprince P. Emergency circulatory support in refractory cardiogenic shock patients in remote institutions: a pilot study (the cardiac-RESCUE program). Eur Heart J 2012; 34:112-20. [DOI: 10.1093/eurheartj/ehs081] [Citation(s) in RCA: 208] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Zhou X, Wang D, Sumpter R, Pattison G, Ballard-Croft C, Zwischenberger JB. Long-term support with an ambulatory percutaneous paracorporeal artificial lung. J Heart Lung Transplant 2012; 31:648-54. [PMID: 22445195 DOI: 10.1016/j.healun.2012.02.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Revised: 01/20/2012] [Accepted: 02/02/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Conventional extracorporeal membrane oxygenation is bulky and non-ambulatory and requires multiple blood transfusions. We hypothesized that a percutaneous, paracorporeal artificial lung (PAL) could be established through a single venous cannulation to provide long-term ambulatory respiratory support. METHODS Our PAL system was tested in 11 healthy sheep. An Avalon Elite dual-lumen cannula (DLC), inserted through the right jugular vein into the superior vena cava, right atrium, and inferior vena cava, was connected to a CentriMag pump and compact hollow-fiber gas exchanger, forming a short-circuit PAL system. All sheep were moved to intensive care unit and were ambulatory after anesthesia recovery. Hemodynamics and device performance were measured daily. RESULTS The ambulatory PALs were successfully established in all sheep. The sheep were awake, ate, and moved freely in the metabolic cage, with no need of artificial nutrition or blood transfusion. All sheep had stable hemodynamics, with 2 liters/min of average circuit flow and hemoglobin levels exceeding 9.2 g/dl throughout the experiment. A progressive decrease of oxygen transfer and carbon dioxide removal capacity was observed. Sheep were euthanized between 10 and 24 days for bleeding (n = 2), gas exchanger failure (n = 6), and DLC issues (n = 3). CONCLUSIONS We successfully established long-term ambulatory PAL for up to 24 days in 11 animals using our patented DLC through a single-site percutaneous venous cannulation. Critical bleeding/thrombosis formation and gas exchanger durability remain two major challenges for long-term-ambulatory PAL.
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Affiliation(s)
- Xiaoqin Zhou
- Department of Surgery, University of Kentucky, College of Medicine, 800 Rose Street, Lexington, KY 40536-0298, USA
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Fuehner T, Kuehn C, Hadem J, Wiesner O, Gottlieb J, Tudorache I, Olsson KM, Greer M, Sommer W, Welte T, Haverich A, Hoeper MM, Warnecke G. Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation. Am J Respir Crit Care Med 2012; 185:763-8. [PMID: 22268135 DOI: 10.1164/rccm.201109-1599oc] [Citation(s) in RCA: 437] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE The use of extracorporeal membrane oxygenation (ECMO) in patients who are awake and spontaneously breathing may represent a novel bridging strategy toward lung transplantation (LuTx). OBJECTIVES To evaluate the outcomes of patients treated with the "awake ECMO" concept as bridge to transplantation. METHODS We performed a retrospective, single-center, intention-to-treat analysis of consecutive LuTx candidates with terminal respiratory or cardiopulmonary failure receiving awake ECMO support. The outcomes were compared with a historical control group of patients treated with conventional mechanical ventilation (MV group) as bridge to transplant. MEASUREMENTS AND MAIN RESULTS Twenty-six patients (58% female; median age, 44 yr; range, 23-62) were included in the awake ECMO group and 34 patients (59% female; median age, 36 yr; range, 18-59) in the MV group. The duration of ECMO support or MV, respectively, was comparable in both groups (awake ECMO: median, 9 d; range, 1-45. MV: median, 15 d; range, 1-71; P = 0.25). Six (23%) of 26 patients in the awake ECMO group and 10 (29%) of 34 patients in the MV group died before a donor organ was available (P = 0.20). Survival at 6 months after LuTx was 80% in the awake ECMO group versus 50% in the MV group (P = 0.02). Patients in the awake ECMO group required shorter postoperative MV (P = 0.04) and showed a trend toward a shorter postoperative hospital stay (P = 0.06). CONCLUSIONS ECMO support in patients who are awake and nonintubated represents a promising bridging strategy, which should be further evaluated to determine its role in patients with end-stage lung disease awaiting LuTx.
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Affiliation(s)
- Thomas Fuehner
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
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Hayes D, Kukreja J, Tobias JD, Ballard HO, Hoopes CW. Ambulatory venovenous extracorporeal respiratory support as a bridge for cystic fibrosis patients to emergent lung transplantation. J Cyst Fibros 2012; 11:40-5. [DOI: 10.1016/j.jcf.2011.07.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 07/22/2011] [Accepted: 07/27/2011] [Indexed: 10/15/2022]
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Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era. Intensive Care Med 2011; 38:210-20. [DOI: 10.1007/s00134-011-2439-2] [Citation(s) in RCA: 305] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 07/06/2011] [Indexed: 11/26/2022]
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Del Sorbo L, Goffi A, Ranieri VM. Mechanical ventilation during acute lung injury: current recommendations and new concepts. Presse Med 2011; 40:e569-83. [PMID: 22104487 DOI: 10.1016/j.lpm.2011.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/05/2011] [Accepted: 05/13/2011] [Indexed: 01/08/2023] Open
Abstract
Despite a very large body of investigations, no effective pharmacological therapies have been found to cure acute lung injury. Hence, supportive care with mechanical ventilation remains the cornerstone of treatment. However, several experimental and clinical studies showed that mechanical ventilation, especially at high tidal volumes and pressures, can cause or aggravate ALI. Therefore, current clinical recommendations are developed with the aim of avoiding ventilator-induced lung injury (VILI) by limiting tidal volume and distending ventilatory pressure according to the results of the ARDS Network trial, which has been to date the only intervention that has showed success in decreasing mortality in patients with ALI/ARDS. In the past decade, a very large body of investigations has determined significant achievements on the pathophysiological knowledge of VILI. Therefore, new perspectives, which will be reviewed in this article, have been defined in terms of the efficiency and efficacy of recognizing, monitoring and treating VILI, which will eventually lead to further significant improvement of outcome in patients with ARDS.
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Affiliation(s)
- Lorenzo Del Sorbo
- Università di Torino, Dipartimento di Anestesiologia e Medicina degli Stati Critici, Ospedale S. Giovanni Battista-Molinette, 10126 Torino, Italy
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Siracuse JJ, Saillant NN, Hauser CJ. Technological advancements in the care of the trauma patient. Eur J Trauma Emerg Surg 2011; 38:241-51. [DOI: 10.1007/s00068-011-0160-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 10/15/2011] [Indexed: 12/11/2022]
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Bermudez CA, Rocha RV, Zaldonis D, Bhama JK, Crespo MM, Shigemura N, Pilewski JM, Sappington PL, Boujoukos AJ, Toyoda Y. Extracorporeal membrane oxygenation as a bridge to lung transplant: midterm outcomes. Ann Thorac Surg 2011; 92:1226-31; discussion 1231-2. [PMID: 21872213 DOI: 10.1016/j.athoracsur.2011.04.122] [Citation(s) in RCA: 136] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/26/2011] [Accepted: 04/29/2011] [Indexed: 01/15/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used occasionally as a bridge to lung transplantation. The impact on mid-term survival is unknown. We analyzed outcomes after lung transplant over a 19-year period in patients who received ECMO support. METHODS From March 1991 to October 2010, 1,305 lung transplants were performed at our institution. Seventeen patients (1.3%) were supported with ECMO before lung transplant. Diagnoses included retransplantation (n = 6), pulmonary fibrosis (n = 6), cystic fibrosis (n = 4), and chronic obstructive pulmonary disease (n = 1). Fifteen patients underwent double lung transplant, one patient had single left lung transplant and one patient had a heart-lung transplant. Venovenous and venoarterial ECMO were implanted in eight and nine cases, respectively. Median duration of support was 3.2 days (range, 1 to 49 days). Mean patient follow-up was 2.3 years. RESULTS Thirty-day, 1-year, and 3-year survivals were 81%, 74%, and 65%, respectively, for the supported patients and 93%, 78%, and 62% in the control group (p = 0.56). Two-year survival was not affected by ECMO type, with survival of five out of nine patients supported by venoarterial ECMO vs seven out of eight patients supported by venovenous ECMO (p = 0.17). At 1- year follow-up, allograft function for the ECMO-supported patients did not differ from the control group (forced expiratory volume in one second, 2.35 L vs 2.09 L, p = 0.39) (forced vital capacity, 3.06 L vs 2.71 L, p = 0.34). CONCLUSIONS Extracorporeal membrane oxygenation as a bridge to lung transplantation is associated with higher perioperative mortality but acceptable mid-term survival in carefully selected patients. Late allograft function did not differ in patients who received ECMO support before lung transplant from those who did not receive ECMO.
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Affiliation(s)
- Christian A Bermudez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Ecmo y ecmo mobile. soporte gardio respiratorio avanzado. REVISTA MÉDICA CLÍNICA LAS CONDES 2011. [DOI: 10.1016/s0716-8640(11)70438-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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