Chest
Volume 144, Issue 3, September 2013, Pages 1018-1025
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Original Research
Transplantation
Organ Allocation Waiting Time During Extracorporeal Bridge to Lung Transplant Affects Outcomes

https://doi.org/10.1378/chest.12-1141Get rights and content

Background

The use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (LTX) is still being debated.

Methods

We performed a retrospective two-center analysis of the relationship between ECMO bridging duration and survival in 25 patients. Further survival analysis was obtained by dividing the patients according to waiting time on ECMO: up to 14 days (Early group) or longer (Late group). We also analyzed the impact of the ventilation strategy during ECMO bridging (ie, spontaneous breathing and noninvasive ventilation [NIV] or intubation and invasive mechanical ventilation [IMV]).

Results

Seventeen of 25 patients underwent a transplant (with a 76% 1-year survival), whereas eight patients died during bridging. In the 17 patients who underwent a transplant, mortality was positively related to waiting days until LTX (hazard ratio [HR], 1.12 per day; 95% CI, 1.02-1.23; P = .02), and the Early group showed better Kaplan-Meier curves (P = .02), higher 1-year survival rates (100% vs 50%, P = .03), and lower morbidity (days on IMV and length of stay in ICU and hospital). During the bridge to transplant, mortality increased steadily with time. Considering the overall outcome of the bridging program (25 patients), bridge duration adversely affected survival (HR, 1.06 per day; 95% CI, 1.01-1.11; P = .015) and 1-year survival (Early, 82% vs Late, 29%; P = .015). Morbidity indexes were lower in patients treated with NIV during the bridge.

Conclusions

The duration of the ECMO bridge is a relevant cofactor in the mortality and morbidity of critically ill patients awaiting organ allocation. The NIV strategy was associated with a less complicated clinical course after LTX.

Section snippets

Materials and Methods

All patients treated with ECMO bridging to LTX from May 2007 to May 2011 in two Italian centers (Ospedale Cà Granda of Milan and Policlinico San Matteo of Pavia) were included in this retrospective analysis. All patients were already listed for LTX and received ECMO support when their end-stage respiratory failure deteriorated to terminal hypoxemia and/or hypercapnia. Some had concomitant right-sided heart failure.

We recorded anthropometric data, the type of lung disease that led to LTX

Results

Twenty-five patients received an extracorporeal bridge to LTX. Population characteristics are described in Table 1. Seventeen of 25 patients (68%) underwent a transplant (Fig 1). None of the patients who did not undergo a transplant survived. None of the deaths while awaiting LTX was due to bleeding or technical problems with ECMO (three patients died of multiple organ failure, two of septic shock, two of cardiogenic shock, and one of intestinal ischemia). Three of the 17 patients who underwent

Discussion

Our report confirms that ECMO bridging is feasible and that the survival rate is good enough to justify its use. However, the main finding of our report is that the duration of ECMO support while awaiting organ allocation strongly affects morbidity and mortality. We also found that patients who maintain spontaneous breathing on NIV during ECMO bridging have a lower morbidity before and after LTX.

We found that the time on ECMO was a significant risk factor for death, either during the bridge or

Conclusions

This report confirms that ECMO bridging is feasible and provides encouraging survival results. It shows, we believe for the first time, that the duration of the ECMO bridge is a critical cofactor for mortality and morbidity both before and after LTX. Furthermore, combining ECMO with NIV may decrease the morbidity of patients bridged to LTX.

Acknowledgments

Author contributions: Dr Crotti had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Crotti: contributed to the clinical management, development of the study, data analysis and interpretation, data review, and writing of the manuscript.

Dr Iotti: contributed to the clinical management, development of ideas and study interpretation, writing and review of manuscript drafts, and approval of the final version

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    Funding/Support: This study was partially funded by the Regione Lombardia “Project for Independent Research in the Intensive Care Field” [13465/2010].

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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