Comparing right- versus left-first implantation in off-pump sequential double-lung transplantation: an observational...

Area of Science:

• Cardiothoracic Surgery
• Transplantation Medicine
• Pulmonary Medicine

Background:

• The traditional perfusion-guided sequence for double-lung transplantation prioritizes implanting the lung with the lowest perfusion to mitigate right ventricular afterload and prevent heart failure.
• A paradigm shift involves adopting a right-first implantation sequence, regardless of lung perfusion, hypothesizing it reduces graft edema during the second lung implantation.

Purpose of the Study:

• To compare the perfusion-guided and right-first lung implantation sequences.
• To evaluate the impact of these sequences on intraoperative extracorporeal membrane oxygenation (ECMO) need and primary graft dysfunction (PGD).

Main Methods:

• Retrospective single-center cohort study of 696 double-lung transplant cases (2008-2021) initiated without ECMO.
• Propensity score-adjusted comparison of right-first versus left-first (perfusion-guided) sequences in cases with native left lung perfusion ≤50%.

Main Results:

• Intraoperative ECMO cannulation was required in 10.96% of right-first cases versus 19.05% of left-first cases (OR 0.448, P=0.0193).
• Primary graft dysfunction grade 3 (PGD3) at 72 hours occurred in 8.02% of right-first cases compared to 15.64% of left-first cases (P=0.1452).
• Right-first implantation did not significantly impact patient survival or chronic lung allograft dysfunction-free survival.

Conclusions:

• The right-first implantation sequence in off-pump double-lung transplantation is associated with a reduced need for intraoperative ECMO.
• This sequence demonstrates a trend towards less PGD grade 3, suggesting potential benefits in early graft outcomes.