Perioperative use of ECMO during double lung transplantation

Lung transplantation has become an established option in end-stage lung disease therapy. Some sequential double-lung transplantations require cardiopulmonary bypass (CPB) support during surgical procedure. However, conventional CPB increases the risks of bleeding and early allograft dysfunction. This report summarizes the perfusion techniques for replacing conventional CPB with extracorporeal membrane oxygenation (ECMO) during sequential double-lung transplantation procedure in our hospital. Between November 2002 and December 2006, nine cases of sequential double-lung transplantation were set up for ECMO during the surgical procedure. All patients suffered from end-stage lung disease. Eight patients were prepared for the procedure via transverse thoracostomy (clamshell) and cannulated through the ascending aorta and right atrium for ECMO before implantation of the second lung. The first patient who underwent bilateral thoracotomy for bilateral sequential lung transplantation required emergency ECMO via the femoral artery and vein during the second lung implantation. The Medtronic centrifugal pump and ECMO package were used for all of the cases. During ECMO, the blood flow was set at 1.8-2.0 L/m2/min; colloid oncotic pressure was maintained at more than 18 mm Hg, with albumin and hematocrit kept at 28% or more. There were two cases of early death in the group; the other cases were weaned from ECMO successfully. Extracorporeal membrane oxygenation duration was 1.83-67 hours, and postoperative intubation was 18-67 hours. As a successful technique of heart-lung support, ECMO can supply hemodynamic stabilization, reducing factors such as ischemia-reperfusion injury, anticoagulation requirement, and systemic inflammatory response for sequential double-lung transplantation.