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Extrakorporale Unterstützungsverfahren bei Lungentransplantation

Extracorporeal support strategies in lung transplantation

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Zeitschrift für Herz-,Thorax- und Gefäßchirurgie Aims and scope

Zusammenfassung

Hintergrund

Die Lungentransplantation hat einen souveränen Stellenwert in der Therapie schwerer therapierefraktärer Lungenerkrankungen. Obwohl chirurgische Technik und perioperative Versorgung hochstandardisiert erscheinen, wird der Einsatz extrakorporaler Verfahren (extrakorporale Zirkulation, EKZ) während der Transplantation hinsichtlich des Risiko-Nutzen-Verhältnisses kontrovers diskutiert.

Ziel der Arbeit

Es soll ein aktueller Überblick über Technik und Ergebnisse der Lungentransplantation gegeben werden, insbesondere im Hinblick auf den Stellenwert der EKZ.

Material und Methoden

Hierzu wird die aktuelle Literatur diskutiert sowie in den Kontext der medizinischen und der technischen Möglichkeiten gestellt.

Ergebnisse

Moderne Operationsverfahren wie die bilaterale sequenzielle Einzellungentransplantation erlauben technisch den Verzicht auf eine EKZ. Dieser Verzicht ist mit einem günstigeren postoperativen Verlauf assoziiert, der durch weniger Blutungskomplikationen und geringere Immunmodulation bedingt ist. Hierdurch können sowohl das primäre Graft-Versagen reduziert als auch das Langzeitüberleben verbessert werden. Eine ungeplante Konversion hin zu einer EKZ sollte jedoch vermieden werden. Es sind konkrete Strategien beschrieben, um präoperativ und frühintraoperativ den Bedarf einer EKZ zu evaluieren.

Schlussfolgerung

Es bestehen keine einheitlichen Empfehlungen hinsichtlich der Anwendung einer EKZ. Zweifelsohne ist aber ein klarer Trend erkennbar, Lungentransplantationen gänzlich ohne die Zuhilfenahme einer EKZ durchzuführen. In der Realität ist die EKZ jedoch nicht in jedem Fall zu vermeiden, allerdings kommt heute mehrheitlich eine venoarterielle extrakorporale Membranoxygenierung (v.a.-ECMO) zum Einsatz, die die klassische Herz-Lungen-Maschine (HLM) nahezu verdrängt hat.

Abstract

Background

Lung transplantation is a well-understood and established method to treat severe symptomatic pulmonary diseases. Despite the highly standardized surgical technique and intraoperative treatment, the use of an extracorporeal support procedure (extracorporeal circulation, ECC) during lung transplantation is controversially discussed with respect to the risk-benefit profile.

Objective

This manuscript provides an overview of current techniques and strategies and outcome of lung transplantation in the particular context of the importance of ECC.

Material and methods

Modern surgical techniques and relevant available literature are discussed to present an overview of the role of ECC in lung transplantation.

Results

Contemporary surgical techniques, such as bilateral sequential single lung transplantation, principally allow the omission of ECC. Results are described to be superior if lung transplantation is performed without ECC due to less bleeding complications and immunomodulation and reduced primary graft dysfunction is reported. Moreover, long-term survival is improved in the case of off-pump transplantation, while unplanned intraoperative conversion to ECC should be avoided at all times. Meaningful strategies are available to assess the need of ECC prior to surgery or at early intraoperative time.

Conclusion

No clear recommendations or guidelines are available regarding the use of ECC in the field of lung transplantation; however, a clear trend towards off-pump strategies for lung transplantation completely without the aid of ECC can be observed. Nevertheless, in particular scenarios, ECC cannot be omitted. In this case, venoarterial extracorporeal membrane oxygenation (ECMO) has become the state of the art support to replace the classical heart-lung machine.

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Authors and Affiliations

  1. Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Hill End Road, UB9 6JH, Harefield, Middlesex, Vereinigtes Königreich

    B. Schmack MD, B. Zych, A. Sabashnikov, A. R. Simon & A.-F. Popov

  2. Klinik für Herzchirurgie, Herz- und Marfanzentrum, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    B. Schmack MD, A. Weymann, A. Ruhparwar & M. Karck

  3. Department of Anaesthetics and Intensive Care Medicine, Kings College Hospital, Kings College Hospital NHS Foundation Trust, Denmark Hill, London, Vereinigtes Königreich

    L. Grossekettler

Authors
  1. B. Schmack MD
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  2. A. Weymann
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  3. B. Zych
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  4. A. Sabashnikov
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  5. L. Grossekettler
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  6. A. Ruhparwar
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  7. M. Karck
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  8. A. R. Simon
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  9. A.-F. Popov
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Corresponding author

Correspondence to B. Schmack MD.

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Interessenkonflikt

B. Schmack, A. Weymann, B. Zych, A. Sabashnikov, L. Grossekettler, A. Ruhparwar, M. Karck, A.R. Simon und A.-F. Popov geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Schmack, B., Weymann, A., Zych, B. et al. Extrakorporale Unterstützungsverfahren bei Lungentransplantation. Z Herz- Thorax- Gefäßchir 31, 78–82 (2017). https://doi.org/10.1007/s00398-016-0090-5

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  • DOI: https://doi.org/10.1007/s00398-016-0090-5

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