Original article：Extracorporeal membrane oxygenation during double-lung transplantation： single center experience

Background For patients with end-stage lung diseases, lung transplantation is the final therapeutic option. Sequential double-lung transplantation is recognized as an established procedure to avoid cardiopulmonary bypass （CPB）. But some of the sequential double-lung transplantations require CPB support during the surgical procedure for various reasons. However, conventional CPB may increase the risk of bleeding and early allograft dysfunction. Extracorporeal membrane oxygenation （ECMO） is more advantageous than conventional CPB during the perioperative period of transplantation. Replacing traditional CPS with ECMO is promising for those patients needing cardiopulmonary support during a sequential double-lung transplantation procedure. This study aimed to summarize the preliminary experience of ECMO practice in lung transplantation.Methods Between November 2002 and October 2008, twelve patients with end-stage lung diseases undergoing sequential double-lung transplantation were subjected to ECMO during the surgical procedure. Eleven patients were prepared for the procedure via transverse thoracostomy （clamshell） and cannulated through the ascending aorta and right atrium for ECMO. 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 （CBIV97R1, Medtronic, Inc., USA） were used for all of the patients. Results During ECMO, the blood flow rate was set between 1.8-2.0 L.m2.min-1 to keep hemodynamic and oxygen saturation stable; colloid oncotic pressure was maintained at more than 18 mmHg with albumin and hematocrit （HCT） kept at 28% or more. Two patients died early in this series and the other 10 patients were weaned from ECMO successfully. The duration of ECMO was 1.38-67.00 hours, and postoperative intubation was 10,5-67.0 hours. Conclusions As an established technique of cardiopulmonary support, ECMO is helpful to keep hemodynamics stable, while reducing risk factors such as ischemia-reperfusion injury, anticoagulation requirement and systemic inflammatory response for sequential double-lung transplantation compared with conventional CPB.

Single-lung transplantation in emphysema:Retrospective study analyzing survival and waiting list mortality

AIM: To performed remains a subject of debate and is the principal aim of the study. METHODS: This retrospective analysis included 73 patients with emphysema(2000-2012). The outcomes of patients undergoing single-lung transplantation(SL)(n = 40) or double-lung transplant(DL)(n = 33) were compared in a Cox multivariate analysis to study the impact of the technique, postoperative complications and acute and chronic rejection on survival rates. Patients were selected for inclusion in the waiting list according to the International Society of Heart Lung Transplantation criteria. Pre and postoperative rehabilitation and prophylaxis, surgical technique and immunosuppressive treatment were similar in every patients. Lung transplantation waiting list information on a national level and retrospective data on emphysema patient survival transplanted in Spain during the study period, was obtained from the lung transplantation registry managed by the National Transplant Organization(ONT). RESULTS: Both groups were comparable in terms of gender and clinical characteristics. We found significant differences in the mean age between the groups, the DL patients being younger as expected from the inclusion criteria. Perioperative complications occurred in 27.6% SL vs 54% DL(P = 0.032). Excluding perioperative mortality, median survival was 65.3 mo for SL and 59.4 mo for DL(P = 0.96). Bronchiolitis obliterans and overall 5-year survival were similar in both groups. Bacterialrespiratory infection, cytomegalovirus and fungal infection rates were higher but not significant in SL. No differences were found between type of transplant and survival(P = 0.48). To support our results, national data on all patients with emphysema in waiting list were obtained(n = 1001). Mortality on the waiting list was 2.4% for SL vs 6.2% for DL. There was no difference in 5 year survival between 235 SL and 430 DL patients transplanted(P = 0.875).CONCLUSION: Our results suggest that SL transplantation in emphysema produce similar survival than DL with less postoperative complication and significant lower mortality in waiting list.