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Mortality after Lung Transplantation for Children Bridged with Extracorporeal Membrane Oxygenation
Kyle Thompson1, Steven J Staffa2, Viviane G Nasr2
1Department of General Surgery.
Insights
Extracorporeal membrane oxygenation (ECMO) is increasingly used for pediatric lung transplant candidates. While ECMO bridging is associated with higher in-hospital mortality, it did not impact 1-year survival or retransplantation rates.
Area of Science:
- Pediatric critical care medicine
- Cardiopulmonary support
- Organ transplantation
Background:
- Extracorporeal membrane oxygenation (ECMO) is a vital bridge therapy for pediatric lung transplant candidates with failing respiratory support.
- The utilization of ECMO as a bridge to lung transplantation in children has notably increased over the study period.
Purpose of the Study:
- To compare in-hospital mortality and a composite outcome of 1-year mortality or retransplantation in pediatric lung transplant recipients bridged with ECMO, mechanical ventilation (MV), or neither.
- To analyze trends in ECMO use for pediatric lung transplantation.
Main Methods:
- Analysis of the United Network for Organ Sharing database for lung transplant recipients aged 20 years or younger between January 2004 and August 2019.
- Categorization of recipients based on respiratory support at transplant: ECMO, MV, or neither.
- Multivariable analysis to assess the impact of support type on in-hospital mortality.
Main Results:
- Of 1,014 pediatric lung transplant recipients, 6.7% used ECMO, 14.2% used MV, and 79.1% used neither.
- Bridging with ECMO (aOR, 3.57) and MV (aOR, 2.67) were independently associated with increased in-hospital mortality.
- No significant difference was observed in the composite outcome of 1-year mortality or retransplantation across the support groups.
Conclusions:
- The use of ECMO as a bridge to pediatric lung transplantation has risen significantly.
- ECMO represents a high-risk bridge strategy, associated with increased in-hospital mortality.
- Further research is needed to identify interventions to improve survival outcomes for pediatric lung transplant recipients bridged with ECMO.
Abstract:
Rationale: Extracorporeal membrane oxygenation (ECMO) is increasingly used to bridge children who are wait-listed and failing conventional respiratory support for lung transplantation. Objectives: To compare in-hospital mortality and a composite outcome of 1-year mortality or retransplantation in children bridged with ECMO, supported with mechanical ventilation (MV), and given neither support. Methods: The United Network for Organ Sharing was used to analyze lung transplant recipients aged ⩽20 years from January 2004 to August 2019. Recipients were categorized according to their degree of respiratory support at the time of transplant, including ECMO, MV, or neither. Multivariable analysis was used to evaluate support type and in-hospital mortality. Results: Of 1,014 children undergoing a lung transplant, 68 (6.7%) required ECMO as a bridge to transplant, 144 (14.2%) required MV, and 802 (79.1%) required neither. Primary diagnosis in the ECMO cohort included cystic fibrosis (43%), pneumonia and/or acute respiratory distress syndrome (10.3%), interstitial pulmonary fibrosis (7.4%), and pulmonary hypertension (5.9%). The number of patients bridged with ECMO increased throughout the study period from 0% in 2004 to 16.7% in 2018. Multivariable analysis showed bridging with both ECMO (adjusted odds ratio, 3.57; 95% confidence interval, 1.42-8.97) and MV (adjusted odds ratio, 2.67; 95% confidence interval, 1.26-5.57) increased in-hospital mortality after lung transplantation. However, there was no difference in composite outcome of mortality and retransplantation at 1 year between the three groups. Conclusions: ECMO to bridge children receiving lung transplantation has increased. Despite this, ECMO is a high-risk bridge strategy for children awaiting lung transplantation. Future research should target interventions that can be focused on improving survival in these patients.
