Toubat Omar, Usman Asad A, Gregorio Paulo, Shin Max, Spelde Audrey, Gutsche Jacob, Cantu Edward, Biscotti Mauer, Bermudez Christian A
Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pa.
Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, Pa.
JTCVS Tech. 2025 Mar 28;31:210-223. doi: 10.1016/j.xjtc.2025.02.020. eCollection 2025 Jun.
To discuss technical strategies and considerations to facilitate intraoperative extracorporeal membrane oxygenation (ECMO) management during lung transplantation.
We review our institutional approach to the management of intraoperative ECMO during bilateral lung transplantation. Our proposed algorithm summarizes technical considerations based on the mechanical circulatory support (MCS) platform encountered in the operating room.
For patients without preoperative ECMO, an assessment of indications and available configurations in anticipation of the need for intraoperative ECMO is required. Our initial MCS approach for isolated respiratory failure is venovenous (VV) ECMO. If patients have pulmonary hypertension or right ventricular dysfunction with acceptable vascular access, then peripheral venoarterial (VA) ECMO is attempted. However, we maintain a low threshold for conversion to central aortic cannulation with a modified Seldinger technique through a clamshell or bilateral anterior thoracotomy incision. For patients bridged to lung transplantation on VV ECMO or venopulmonary (VPa) ECMO, our initial approach is to reverse flow through existing venous cannulas when possible and provide outflow through central aortic cannulation. Finally, for patients bridged to lung transplantation on peripheral VA ECMO, conversion to a central VA ECMO platform is preferred in the setting of poor flow or central hypoxemia. Importantly, all patients at our institution requiring MCS during lung transplantation are supported on a modified circuit that allows for rapid conversion from VA ECMO to full cardiopulmonary bypass (CPB) as needed.
We propose a simple and technically feasible algorithm to facilitate the intraoperative conversion of VV, VPa, and VA ECMO patients to a modified central VA ECMO/CPB platform during bilateral lung transplantation.
探讨在肺移植术中促进体外膜肺氧合（ECMO）管理的技术策略及注意事项。
我们回顾了本机构在双侧肺移植术中对术中ECMO管理的方法。我们提出的算法总结了基于手术室中遇到的机械循环支持（MCS）平台的技术考量。
对于术前未使用ECMO的患者，需要在预期术中需要ECMO时评估适应证和可用配置。我们针对单纯呼吸衰竭的初始MCS方法是静脉-静脉（VV）ECMO。如果患者有肺动脉高压或右心室功能障碍且血管通路可接受，则尝试外周静脉-动脉（VA）ECMO。然而，我们对于通过蚌式或双侧前开胸切口采用改良Seldinger技术转换为中心主动脉插管的阈值较低。对于通过VV ECMO或静脉-肺（VPa）ECMO过渡到肺移植的患者，我们的初始方法是尽可能通过现有的静脉插管反向血流，并通过中心主动脉插管提供流出道。最后，对于通过外周VA ECMO过渡到肺移植的患者，在血流不佳或中心性低氧血症的情况下，首选转换为中心VA ECMO平台。重要的是，我们机构所有在肺移植术中需要MCS的患者都在一个改良的回路中得到支持，该回路允许根据需要从VA ECMO快速转换为全心肺转流（CPB）。
我们提出了一种简单且技术上可行的算法，以促进双侧肺移植术中VV、VPa和VA ECMO患者向改良的中心VA ECMO/CPB平台的术中转换。
