Experience of extracorporeal membrane oxygenation as a bridge to lung transplantation in France

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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.

Section snippets

Patients and Methods

This retrospective analysis, which received approval of the Agence de la Biomédecine, included all patients who received ECMO support as a bridge to LTx between July 2007 and July 2011. July 2007 was chosen because the new French high-emergency LTx system (HELTx) rules were implemented at this date.4 These new rules, which allow for rapid organ allocation for patients at imminent risk of death, have led to much greater use of ECMO as a bridge to LTx in France.

The organization of HELTx in France

Study Group

During the study period, 36 patients received ECMO as a bridge to LTx in 9 of the 11 French LTx centers. The 2 remaining centers did not use ECMO for this indication. The main characteristics of the 36 patients are reported in Table 2. The primary diagnosis was CF for 20 patients (56%), PF for 11 (30%), and re-LTx in 3. The indication for LTx in the 2 remaining patients was bronchiolitis obliterans related to allogenic stem-cell transplantation and respiratory failure after lung volume

Outcome

Figure 1 depicts the flow of patients in the study. The main ECMO complications are listed in Table 3. No patient could be weaned from ECMO before LTx or death. Six patients died (16.7%) before LTx (PF in 4; other diagnoses in 2), and 30 (83.3%) eventually underwent LTx. ECMO was a successful bridge to LTx for all CF patients compared with 7 of 11 PF patients (63.6%) and 2 of 5 patients (40%) with another diagnosis. The median time between ECMO initiation and death for the 6 patients who died

Discussion

The most salient features of our exhaustive description of the experience of ECMO as a bridge to LTx in France are the following: among 36 patients treated in 9 of the 11 LTx centers in this series, which represents one of the largest series published to date, ECMO was a successful bridge to LTx for 30 patients. The survival rate with ECMO by intention-to-treat analysis was 55.4% at 1 year and 50.4% at 2 years, ranging from 21% for PF patients to 71% for CF patients.

On a theoretical basis,

Disclosure statement

None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.

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