Current intraoperative mechanical circulatory support strategies for bilateral lung transplantation surgery

Authors

• Omar Toubat, Univ. of Pennsylvania Medical Center
• Asad A. Usman, Univ. of Pennsylvania Medical CenterFollow
• Paulo Gregorio, Univ. of Pennsylvania Medical Center
• Max Shin, Univ. of Pennsylvania Medical Center
• Audrey Spelde, Univ. of Pennsylvania Medical Center
• Jacob Gutsche, Univ. of Pennsylvania Medical Center
• Edward Cantu, University of Kentucky
• Mauer Biscotti, Univ. of Pennsylvania Medical Center
• Christian A. Bermudez, Univ. of Pennsylvania Medical Center

Abstract

Objective: To discuss technical strategies and considerations to facilitate intraoperative extracorporeal membrane oxygenation (ECMO) management during lung transplantation. Methods: 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. Results: 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. Conclusions: 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.

Document Type

Article

Publication Date

6-1-2025

Notes/Citation Information

Publisher Copyright: © 2025 The Authors

Digital Object Identifier (DOI)

10.1016/j.xjtc.2025.02.020

Archival?

Archival

Repository Citation

Toubat, Omar; Usman, Asad A.; Gregorio, Paulo; Shin, Max; Spelde, Audrey; Gutsche, Jacob; Cantu, Edward; Biscotti, Mauer; and Bermudez, Christian A., "Current intraoperative mechanical circulatory support strategies for bilateral lung transplantation surgery" (2025). Surgery Faculty Publications. 83.
https://uknowledge.uky.edu/surgery_facpub/83