Indications for prolongation of ECMO into the early postoperative period in lung transplantation How we do it

Transcription

1 Indications for prolongation of ECMO into the early postoperative period in lung transplantation How we do it W Klepetko, MD Professor of Thoracic Surgery HEAD: DIVISION OF THORACIC SURGERY MEDICAL UNIVERSITY OF VIENNA

2 The presenter has nothing to disclose.

3 First lung syndrome Parenchymal reperfusion damage Full CO into the first implanted lung

4 First lung syndrome POD 1 POD 2 POD 6 POD 18 POD 30

5 Rationale for the use of intra-op v/a ECMO > Protective ventilation Respiration with lower tidal volumes is lung-protective (The ARDS Network, N Engl J Med, 342, May 2000) > Controlled reperfusion Controlled reperfusion protects lung grafts (Bhabra et al., Ann Thorac Surg 1998)

6 Length of Controlled Reperfusion 5 min 10 min 30 min During entire implantation procedure Why not taking advantage of the beneficial effects of controlled reperfusion by prolongation of ECMO into the early postoperative period in special situations

7 2002

8 16 Donor Pigs Braindeath 4 hrs Lung harvesting Left SLUTX 22 hrs cold storage Group B ECMO intraop + prolonged no ECMO Group A

9 2015 Survival (%) Adult Lung Transplants Kaplan-Meier Survival by Diagnosis (Transplants: January 1990 June 2013) Alpha-1 (N=2,904) CF (N=7,336) COPD (N=15,064) IPF (N=10,438) IPAH (N=1,584) Sarcoidosis (N=1,136) All pair-wise comparisons were significant at p < 0.05 except Alpha-1 vs. IPAH, Alpha-1 vs. Sarcoidosis, COPD vs. IPAH, COPD vs. Sarcoidosis, IPAH vs. Sarcoidosis Years Median survival (years): Alpha-1=6.5 CF=8.5 COPD=5.5 IPF=4.7 IPAH=5.7 Sarcoidosis=6.1 JHLT Oct; 34(10):

10 Adult Lung Transplants Kaplan-Meier Survival by Diagnosis Conditional on Survival to 3 Months (Transplants: January 1990 June 2013) Alpha-1 (N=2,522) CF (N=6,510) COPD (N=13,446) IPF (N=8,844) IPAH (N=1,203) Sarcoidosis (N=964) Survival (%) All pair-wise comparisons were significant at p < 0.05 except Alpha-1 vs. Sarcoidosis, COPD vs. IPF, CF vs. IPAH, and IPAH vs. Sarcoidosis 20 0 Median survival (years): Alpha-1=7.8; CF=10.0; COPD=6.2; IPF=5.8; IPAH=9.2; Sarcoidosis= Years JHLT Oct; 34(10):

11 Retrospective analysis: January 2000 and December patients: Group A: 41 intra + postop ECMO vs Group B: 31 intraop ECMO only Survival (p = 0.189) Survival rates (p = 0.189) intraop+prolonged intraop only 90-day 92.7 % 83,9 % 1-year 90.2 % 77,4 % 3-year 87.4 % 77,4 % 5-year 87.4 % 77,4 %

12 Transplantation Feb;99(2): n Median 90 d survival (%) BLTX-ECMO historic control groups: BLTX-ventilation HLTX Diagnosis in BLTX-ECMO: > ipah (n=17) > PVOD (n=3) > Sarcoidosis (n=3) ECMO median: 8 days [5-19]

13 Annual use of ECMO in LTx Over time, we have gradually expanded the use of ECMO to a more preemptive application in every standard LTx IntraOp + prolonged IntraOp ECMO use

14 Review of n = 582 Lutx Overall survival intraop ECMO prolonged postop ECMO no ECMO

15 Mode of Intraoperative ECMO Flow level adjusted to maintain pulsatile PA flow in first lung Monitoring with PAP and EtCO2

16 Decannulation at the end of implantation in presence of hemodynamical and respiratory stability

17 Installation of closed circuit perfusion on the table...followed by observation of hemodynamic and respiratory performance during closure of chest

18 Criteria for ECMO prolongation Closing of the chest ABG + hemodynamics ABG + hemodynamics PaO 2 /FiO 2 < 100 mpap > 2/3 of msap clear trend of worsening between the two time points v/a ECMO transfer to groin

19 Transfer to ICU Monitoring of limb saturation Pulsatile PAP curve EtCO2

20 Mode of prolonged ECMO Low dose heparinisation Flow according to clinical needs Blood flow > 2 l/min mpap < 30 mmhg Maintainance of pulsatile PA flow

21 Criteria for weaning from ECMO Non agressive ventilation Hemodynamical stability Mean PAP < 50 % msap 10 min test period with 1,0 L/min flow

22 Prospective Analysis of PGD in 90 consecutive standard patients transplanted in Vienna Unpublished data, to be presented at ISHLT 2018 Patients No 0.0% morepgd prolonged 3 at 72 ECMO hrs at 72 hrs 10 0 hrs 24 hrs 48 hrs 72 hrs Excluded: SLTx, ReTx, Pediatric Tx, Multiorgan Tx, Bridging Unpublished data, to be presented at ISHLT 2018

23 Prospective Analysis of PGD in 90 consecutive standard patients transplanted in Vienna Patients hrs 24 hrs 48 hrs 72 hrs 72 % extubated at t72 Unpublished data, to be presented at ISHLT 2018

24 The vicious circle of PGD. how to interrupt it NON OPTIMAL DONOR LUNG EVLP ISCHEMIC INJURY NEED FOR UNPLANNED ECMO INTRAOP ECMO ADDITIONAL DAMAGE REPERFUSION DAMAGE NEED FOR AGGRESSIVE VENT + CATECHOLAMINES POSTOP PROLONGED ECMO

25 Vienna LuTx Team Department of Thoracic Surgery, MUV Director K Hoetzenecker Surgeons S Taghavi G Lang J Matilla B Moser Pulmonologists P Jaksch G Muraközy C Lambers etc. etc. etc.