Transient perioperative inflammation following lung transplantation and major thoracic surgery with elective extracorporeal support: a prospective observational study

Postoperative Liver Dysfunction After Lung Transplantation With Extracorporeal Life Support and 1-Year Mortality-A Cohort Study

OBJECTIVES

Extracorporeal life support, including venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB), triggers a pronounced inflammatory response and has been linked to postoperative liver dysfunction. Such dysfunction may negatively affect clinical outcomes after lung transplantation. Given that double-lung transplantation increasingly involves venoarterial ECMO, this work was designed to analyze the incidence of liver injury post-transplant and its impact on outcomes, specifically duration of intensive care unit (ICU) stay and 1-year mortality.

DESIGN

Retrospective analysis.

SETTING

Single university hospital.

INTERVENTIONS

None.

PARTICIPANTS

Data from 1,350 consecutive patients who underwent lung transplantation between January 2009 and April 2023 were analyzed.

MEASUREMENTS AND MAIN RESULTS

Hepatic injury occurring within the first 12 postoperative days was classified as hypoxic liver dysfunction, drug-induced liver injury, or cholestasis. The corresponding incidences were 4%, 23%, and 52%, respectively. All were associated with an increased length of ICU stay. Owing to the multiple medications these patients receive post-transplantation, a clear distinction between drug-induced liver injury and a mild form of hypoxic liver dysfunction is difficult. However, only the latter was independently linked with increased 1-year mortality amounting to 35%. Patients who developed hypoxic liver dysfunction were more frequently operated on CPB or required prolonged ECMO support.

CONCLUSION

Lung transplantation involving CPB or extended perioperative ECMO support significantly increases the risk of severe postoperative liver dysfunction associated with poorer outcomes. However, brief intraoperative ECMO deployment does not appear to carry this risk.

The role of extracorporeal membrane oxygenation in thoracic anesthesia

PURPOSE OF REVIEW

Circulatory and respiratory support with extracorporeal membrane oxygenation (ECMO) has gained widespread acceptance during high-end thoracic surgery. The purpose of this review is to summarize the recent knowledge and give an outlook for future developments.

RECENT FINDINGS

A personalized approach of ECMO use is state of the art for monitoring during surgery. Personalization is increasingly applied during anesthesia for high-end surgery nowadays. This is reflected in the point of care testing (POCT) for anticoagulation and cardiac function during surgery on ECMO combining specific patient data into tailored algorithms. For optimizing protective ventilation MP (mechanical power) is a promising parameter for the future. These personalized methods incorporating numerous patient data are promising for the improvement of morbidity and mortality in high-end thoracic surgery. However, clinical data supporting improvement are not available to date but can be awaited in the future.

SUMMARY

Clinical practice during surgery on ECMO is increasingly personalized. The effect of personalization on morbidity and mortality must be examined in the future. Undoubtedly, an increase in knowledge can be expected from this trend towards personalization.

Peri-Operative Changes of Inflammatory Markers and Their Implications in Pulmonary Endarterectomy

Pulmonary endarterectomy (PEA) is used to treat chronic thromboembolic pulmonary hypertension (CTEPH) patients, and it can effectively remove organized thrombotic materials and proliferative intima as well as improve hemodynamics. It has been reported that the levels of several inflammatory factors were altered in the peri-operative period of PEA. Even though their specific role remains unknown, this could have some relevance. In this study, we reviewed the recently published data addressing these factors in PEA, attempting to understand their potential implications.

Follistatin-like 1 and Biomarkers of Neutrophil Activation Are Associated with Poor Short-Term Outcome after Lung Transplantation on VA-ECMO

The investigation of biomarkers associated with undesired outcome following lung transplantation (LuTX) is essential for a better understanding of the underlying pathophysiology, an earlier identification of susceptible recipients and the development of targeted therapeutic options. We therefore determined the longitudinal perioperative course of putative cytokines related to neutrophil activation (chemokine CC motif ligand 4 (CCL-4), interleukin (IL)-23 and Lipocalin 2 (LCN2)) and a cytokine that has been implicated in graft-versus-host disease (Follistatin-like 1 (FSTL1)) in 42 consecutive patients undergoing LuTX. We plotted receiver-operating curves (ROC) to assess the predictive power of the measured cytokines for short-term outcomes namely primary graft dysfunction (PGD), early complications requiring extracorporeal membrane oxygenation (ECMO), and a high postoperative sequential organ failure assessment (SOFA). All cytokines increased immediately after surgery. ROC analyses determined significant associations between CCL4 and a high SOFA score (area under the curve (AUC) 0.74 (95%CI:0.5−0.9; p < 0.05), between LCN2 and postoperative ECMO support (AUC 0.73 (95%CI:0.5−0.9; p < 0.05), and between FSTL1 and PGD (AUC 0.70 (95%CI:0.5−0.9; p < 0.05). The serum concentrations of the neutrophil-derived cytokines LCN2 and CCL4 as well as FSTL1 were all related to poor outcome after LuTX. The specific predictive power, however, still has to be assessed in larger trials. The potential role of FSTL1 as a biomarker in the development of PGD could be of great interest particularly since this protein appears to play a crucial role in allograft tolerance.