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Lung transplantation via cardiopulmonary bypass: excellent survival outcomes from extended criteria donors

  • Hirosh Taka
  • Kentaroh MiyoshiEmail author
  • Takeshi Kurosaki
  • Takuma Douguchi
  • Hideshi Itoh
  • Seiichiro Sugimoto
  • Masaomi Yamane
  • Motomu Kobayashi
  • Shingo Kasahara
  • Takahiro Oto
Original Article
  • 44 Downloads

Abstract

Objectives

The role of intraoperative cardiopulmonary bypass (CPB) in lung transplant (LTx) surgery is controversial. CPB enables slow pulmonary reperfusion and initial ventilation with low oxygen concentrations, both theoretically protective of transplanted lungs. In this study, we explored clinical outcomes following extended criteria donor LTx surgery implementing a thoroughly protective allograft reperfusion strategy using CPB.

Methods

Thirty-nine consecutive adult patients who underwent bilateral LTx with elective CPB and protective allograft reperfusion were reviewed. Bilaterally implanted lungs were reperfused simultaneously, via slow CPB flow reduction and initial ventilation with 21% oxygen and nitric oxide, followed by a brief modified ultrafiltration. During weaning from CPB, mean pulmonary arterial pressure was strictly maintained at 10–15 mmHg by controlling CPB and pulmonary flow. The clinical outcomes in 23 patients who received lungs from extended criteria donors (ECD group) were elucidated and compared to 16 patients undergoing LTx from standard criteria donors (SCD group).

Results

No life-threatening deterioration was observed to graft functionality during the first 72 h after LTx in the ECD group; however, only one patient required post-transplant extracorporeal membrane oxygenation. In three of 23 ECD LTx patients (12%), surgical revision for bleeding was required. Survival outcomes for the ECD group were favorable, with 100% survival at 6-months, 87.0% at 1-year, and 80.7% at 5-years. Outcomes in the ECD group were comparable to those in the SCD group.

Conclusions

Despite a certain extent of risk associated with full-dose heparinization, use of CPB does not undermine survival outcomes after ECD LTx surgery if protective allograft reperfusion is securely performed.

Keywords

Lung transplantation Cardiopulmonary bypass Protective allograft reperfusion Extended criteria donor 

Notes

Acknowledgements

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.

References

  1. 1.
    Date H. Current status and problems of lung transplantation in Japan. J Thorac Dis. 2016;8:631.S636.CrossRefGoogle Scholar
  2. 2.
    Sato M, Okada Y, Oto T, Minami M, Shiraishi T, Nagayasu T, et al. Registry of the Japanese society of lung and heart-lung transplantation: the official Japanese lung transplantation report 2014. Gen Thorac Cardiovasc Surg. 2014;62:594.601.Google Scholar
  3. 3.
    Hoshikawa Y, Okada Y, Ashikari J, Matsuda Y, Nikawa H, Noda M, et al. Medical consultant system for improving lung transplantation opportunities and outcomes in Japan. Transpl Proc. 2015;47:746–50.CrossRefGoogle Scholar
  4. 4.
    Mulligan MJ, Sanchez PG, Evans CF, Wang Y, Kon ZN, Rajagopal K, et al. The use of extended criteria donors decreases one-year survival in high-risk lung recipients: a review of the United Network of Organ Sharing Database. J Thorac Cardiovasc Surg. 2016;152:891.898.CrossRefGoogle Scholar
  5. 5.
    Moreno P, Alvarez A, Santos F, Vaquero JM, Baamonde C, Redel J, et al. Extended recipients but not extended donors are associated with poor outcomes following lung transplantation. Eur J Cardiothorac Surg. 2014;45:1040.1047.CrossRefGoogle Scholar
  6. 6.
    Sommer W, Kühn C, Tudorache, Avsar M, Gottlieb J, Boethig D, et al. Extended criteria donor lungs and clinical outcome: results of an alternative allocation algorithm. J Heart Lung Transpl. 2013;32:1065.1072.CrossRefGoogle Scholar
  7. 7.
    Kotecha S, Hobson J, Fuller J, Paul E, Levvey BJ, Whitford H, et al. Continued successful evolution of extended criteria donor lungs for transplantation. Ann Thorac Surg. 2017;104:1702–9.k.CrossRefGoogle Scholar
  8. 8.
    Liu Y, Liu Y, Su L, Jiang SJ. Recipient-related clinical risk factors for primary graft dysfunction after lung transplantation: a systematic review and meta-analysis. PLoS One. 2014;9:e92773.CrossRefGoogle Scholar
  9. 9.
    Diamond JM, Lee JC, Kawut SM, Shah RJ, Localio AR, Bellamy SL, et al. Clinical risk factors for primary graft dysfunction after lung transplantation. Am J Respir Crit Care Med. 2013;187:527.534.CrossRefGoogle Scholar
  10. 10.
    Aeba R, Griffith BP, Kormos RL, Armitage JM, Gasior TA, Fuhrman CR, et al. Effect of cardiopulmonary bypass on early graft dysfunction in clinical lung transplantation. Ann Thorac Surg. 1994;57:715.722.CrossRefGoogle Scholar
  11. 11.
    Gammie JS, Cheul Lee J, Pham SM, Keenan RJ, Weyant RJ, Hattler BG, et al. Cardiopulmonary bypass is associated with early allograft dysfunction but not death after double-lung transplantation. J Thorac Cardiovasc Surg. 1998;115:990.995.Google Scholar
  12. 12.
    Szeto WY, Kreisel D, Karakousis GC, Pochettino A, Sterman DH, Kotloff RM, et al. Cardiopulmonary bypass for bilateral sequential lung transplantation in patients with chronic obstructive pulmonary disease without adverse effect on lung function or clinical outcome. J Thorac Cardiovasc Surg. 2002;124:241.249.CrossRefGoogle Scholar
  13. 13.
    De Boer WJ, Hepkema BG, Loef BG, van der Bij W, Verschuuren EA, de Vries HJ, et al. Survival benefit of cardiopulmonary bypass support in bilateral lung transplantation for emphysema patients. Transplantation. 2002;73:1621.1627.Google Scholar
  14. 14.
    Pochettino A, Augoustides JG, Kowalchuk DA, Watcha SM, Cowie D, Jobes DR, et al. Cardiopulmonary bypass for lung transplantation in cystic fibrosis: pilot evaluation of perioperative outcome. J Cardiothorac Vasc Anesth. 2007;21:208.211.CrossRefGoogle Scholar
  15. 15.
    Sabashnikov A, Weymann A, Mohite PN, Zych B, Patil NP, García Sáez D, et al. Risk factors predictive of one-year mortality after lung transplantation. Eur J Cardiothorac Surg. 2014;46:e82.e88.Google Scholar
  16. 16.
    Bates M, Factor M, Parrino E, Bansal A, Rampolia R, Seoane L, et al. Lung transplantation and the routine use of cardiopulmonary bypass and median sternotomy: experience at the ochsner multi-organ transplant institute. Oschner J. 2017;17:38–41.Google Scholar
  17. 17.
    Fiser SM, Kron IL, Long SM, Long SM, Kaza AK, Kron IL. Controlled perfusion decreases reperfusion injury after high-flow reperfusion. J Heart Lung Transpl. 2002;21:687.691.Google Scholar
  18. 18.
    Singh RR, Laubach VE, Ellman PI, Reece TB, Unger E, Kron IL, et al. Attenuation of lung reperfusion injury by modified ventilation and reperfusion techniques. J Heart Lung Transpl. 2006;25:1467–73.CrossRefGoogle Scholar
  19. 19.
    Kotani Y, Honjo O, Goto K, Fujita Y, Ito A, Nakakura M, et al. Modified low-flow ultrafiltration ameliorates hemodynamics and early graft function and reduces blood loss in living-donor lobar lung transplantation. J Heart Lung Transpl. 2009;28:340.346.CrossRefGoogle Scholar
  20. 20.
    Christie JD, Carby M, Bag R, Corris P, Hertz M, Weill D. Report of the ISHLT working group on primary lung graft dysfunction part II: definition. A consensus statement of the international society for heart and lung transplantation. J Heart Lung Transpl. 2005;24:1454.1459.Google Scholar
  21. 21.
    Oto T, Levvey BJ, Whitford H, Griffiths AP, Kotsimbos T, Williams TJ, et al. Feasibility and utility of a lung donor score: correlation with early post-transplant outcomes. Ann Thorac Surg. 2007;83(1):257–63.CrossRefGoogle Scholar
  22. 22.
    Marczin N, Royston D, Yacoub M. Pro: lung transplantation should be routinely performed with cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2000;14:739.745.CrossRefGoogle Scholar
  23. 23.
    Rozé H, Thumerel M, Barandon L, Dromer C, Perrier V, Jougon J, et al. Cardiopulmonary bypass during a second-lung implantation improves postoperative oxygenation after sequential double-lung transplantation. J Cardiothorac Vasc Aneth. 2013;27:467.473.Google Scholar
  24. 24.
    Cypel M, Yeung JC, Machuca T, Chen M, Singer LG, Yasufuku K, et al. Experience with the first 50 ex vivo lung perfusions in clinical transplantation. J Thorac Cardiovasc Surg. 2012;144:1200.1206.CrossRefGoogle Scholar
  25. 25.
    Biscotti M, Yang J, Sonett J, Bacchetta M. Comparison of extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation. J Thorac Cardiovasc Surg. 2014;148:2410.2415.CrossRefGoogle Scholar
  26. 26.
    Bermudez CA, Shiose A, Esper SA, Shigemura N, D’Cunha J, Bhama JK, et al. Outcomes of intraoperative venoarterial extracorporeal membrane oxygenation versus cardiopulmonary bypass during lung transplantation. Ann Thorac Surg. 2014;98:1936–42.CrossRefGoogle Scholar
  27. 27.
    Machuca TN, Collaud S, Mercier O, Cheung M, Cunningham V, Kim SJ, et al. Outcomes of intraoperative extracorporeal membrane oxygenation versus cardiopulmonary bypass for lung transplantation. J Thorac Cardiovasc Surg. 2015;149:1152–7.CrossRefGoogle Scholar
  28. 28.
    Hoechter DJ, von Dossow V, Winter H, Muller HH, Meiser B, Neurohr C, et al. The Munich lung transplant group: intraoperative extracorporeal circulation in lung transplantation. Thorac Cardiovasc Surg. 2015;63:706–14.CrossRefGoogle Scholar
  29. 29.
    Ius F, Sommer W, Tudorache I, Avsar M, Siemeni T, Salman J, et al. Five-year experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: indications and midterm results. J Heart Lung Transpl. 2016;35:49–58.CrossRefGoogle Scholar
  30. 30.
    Moser B, Jacsch P, Taghavi S, Muraközy G, Lang G, Hager H, et al. Lung transplantation for idiopathic pulmonary arterial hypertension intraoperative and postoperatively prolonged extracorporeal membrane oxygenation provides optimally controlled reperfusion and excellent outcome. Eur J Cardiothorac Surg. 2018;53:178–85.CrossRefGoogle Scholar

Copyright information

© The Japanese Association for Thoracic Surgery 2019

Authors and Affiliations

  • Hirosh Taka
    • 1
  • Kentaroh Miyoshi
    • 2
    Email author
  • Takeshi Kurosaki
    • 3
  • Takuma Douguchi
    • 1
  • Hideshi Itoh
    • 4
  • Seiichiro Sugimoto
    • 3
  • Masaomi Yamane
    • 3
  • Motomu Kobayashi
    • 5
  • Shingo Kasahara
    • 6
  • Takahiro Oto
    • 3
  1. 1.Department of Clinical EngineeringOkayama University HospitalOkayamaJapan
  2. 2.Department of Thoracic SurgeryOkayama Medical Center/Okayama University HospitalOkayamaJapan
  3. 3.Department of Thoracic Surgery/Organ Transplant CenterOkayama University HospitalOkayamaJapan
  4. 4.Department of Medical Engineering, Faculty of Health SciencesJunshin Gakuen UniversityFukuokaJapan
  5. 5.Department of AnesthesiologyOkayama University HospitalOkayamaJapan
  6. 6.Department of Cardiovascular SurgeryOkayama University HospitalOkayamaJapan

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