Innovative use of Protek Duo during bilateral lung transplant with Veno-Arterial Extracorporeal Membrane Oxygenation assistance.

V-A ECMO during bilateral lung transplantation is routinely used when extracorporeal support is needed, in particular in case of patients affected by pulmonary hypertension. We report the case of a patient successfully transplanted with V-A ECMO assistance using a percutaneous double lumen cannula as venous drainage (Protek Duo, CardiacAssist Inc., Pittsburgh, PA) and central aortic cannulation. The double lumen cannula allowed an optimal drainage of the venous system and effective emptying of right heart chambers.

Extracorporeal life support during and after bilateral sequential lung transplantation in patients with pulmonary artery hypertension.

The use of extracorporeal membrane oxygenator instead of standard cardiopulmonary bypass during lung transplantation is debatable. Moreover, recently, the concept of prolonged postoperative extracorporeal membrane oxygenator (ECMO) support has been introduced in many transplant centers to prevent primary graft dysfunction (PGD) and improve early and long-term results. The objective of this study was to review the results of our extracorporeal life support strategy during and after bilateral sequential lung transplantation (BSLT) for pulmonary artery hypertension. We review retrospectively our experience in BSLT for pulmonary artery hypertension between January 2010 and August 2018. A total of 38 patients were identified. Nine patients were transplanted using cardiopulmonary bypass (CPB), in eight cases CPB was followed by a prolonged ECMO (pECMO) support, 14 patients were transplanted on central ECMO support, and seven patients were transplanted with central ECMO support followed by a pECMO assistance. The effects of different support strategies were evaluated, in particular in-hospital morbidity, mortality, incidence of PGD, and long-term follow-up. The use of CPB was associated with poor postoperative results and worse long-term survival compared with ECMO-supported patients. Predictive preoperative factors for the need of intraoperative CPB instead of ECMO were identified. The pECMO strategy had a favorable effect to mitigate postoperative morbidity and mortality, not only in intraoperative ECMO-supported patients, but even in CPB-supported cases. In our experience, ECMO may be considered as the first choice circulatory support for lung transplantation. Sometimes, in very complex cases, CBP is still necessary. The pECMO strategy is very effective to reduce incidence of PGD even in CPB-supported patients.

Is Pulmonary Artery Pulsatility Index (PAPi) a Predictor of Outcome after Pulmonary Endarterectomy?

Background: Pulmonary endarterectomy (PEA) is the gold standard therapy for chronic thromboembolic pulmonary hypertension (CTEPH). Traditionally, pulmonary vascular resistance (PVR) represents the main prognostic factor after surgery. The pulmonary artery pulsatility index (PAPi) has been proposed for the assessment of RV in advanced heart failure, but it has never been applied in CTEPH patients. The aim of the present study is to describe PAPi in patients who underwent PEA, before and after surgery, and to define its predictive impact on postoperative outcomes. Methods: We retrospectively reviewed 188 consecutive adult patients who underwent PEA, between December 2003 and December 2021. PAPi was calculated for 186 patients and reported. Patients were partitioned in two groups using median preoperative PAPi as cutoff value: Group 1 with PAPi ≤ 8.6 (n = 94) and Group 2 with PAPi > 8.6 (n = 92). The propensity-score-matched analysis identified 67 pairs: Early outcomes were compared between two groups. Results: Mean preoperative PAPi was 10.3 ± 7.2. Considering matched populations, no differences emerged in terms of postoperative hemodynamics; Group 1 demonstrated higher 90-day mortality significance (10.4% vs. 3.0%, p = 0.082); the need for mechanical circulatory support (MCS) was similar, but successful weaning was unlikely (25% vs. 85.7%, p = 0.032). Conclusions: Mean PAPi in the CTEPH population is higher than in other diseases. Low PAPi (≤8.6) seems to be associated with lower postoperative survival and successful weaning from MCS.

Pulmonary endarterectomy: an alternative to circulatory arrest and deep hypothermia: mid-term results.

BACKGROUND: The current surgical technique for pulmonary endarterectomy (PEA) involves the use of deep hypothermia and circulatory arrest at 18 degrees C (DHCA). Our experience started in 2004 when we decided to use an original alternative strategy which consists of avoiding deep hypothermia and subsequent circulatory arrest by using moderate hypothermia at 26 degrees C, and maintaining a bloodless field. This can be achieved by means of negative pressure in the left heart chambers and appropriate pump flow modulation in order to maintain the mixed venous oxygen saturation (SVO(2)) higher than 65%. MATERIALS AND METHODS: From June 2004 to June 2007, 40 consecutive patients were operated on in our department with this strategy. The aim of this article is to report the early results for all patients and the complete six-month follow-up for 30 subjects who have reached this end-point at the time of writing. The mean temperature during extracorporeal circulation was 25.9 degrees C; core temperature was lowered to 21 degrees C in only one patient and an 8 min DHCA was performed in order to complete the PEA. RESULTS: Two patients died (6.6%): one on the third postoperative day due to myocardial infarct, requiring an ECMO implantation. The other patient died from septic shock. The six-month follow-up, performed in all other patients, included clinical and hemodynamic evaluation. Pulmonary vascular resistance (PVR) decreased from 793.5+/-284 dyn/cm/s(-5) to 286+/-143 (p=0.000). A comparable reduction of mean pulmonary arterial pressure and an increase of cardiac output were also observed. CONCLUSIONS: The results confirm that adequate removal of pulmonary artery obstructive lesions can also be achieved with an operative procedure that avoids or reduces the use of DHCA while allowing a bloodless field during PEA interventions. This technique may limit the well known adverse effects of DHCA due to organ hypoperfusion, improving the postoperative recovery of the patients.

Pulmonary endarterectomy: is there an alternative to profound hypothermia with cardiocirculatory arrest?

The current surgical strategy for pulmonary endarterectomy (PEA) involves the use of extracorporeal circulation and hypothermic circulatory arrest (HCA). The aim of the present study was to test the feasibility of a different strategy of extracorporeal circulation, which could prevent bronchial back bleeding and allow a bloodless operating field, avoiding the risks associated with HCA in patients undergoing pulmonary endarterectomy. Between June 2004 and September 2005, eight patients underwent PEA without HCA. We introduced a double venting of the left heart sections, utilizing two cannulas placed in the left ventricle and atrium. Both vent cannulas are connected with vacuum device to prevent back-bleeding and left heart distension from the large amount of bronchial flow. We were able to perform pulmonary endarterectomy avoiding circulatory arrest and deep hypothermia without sacrificing the effectiveness of the procedure. The initial encouraging results have convinced us to apply systematically this technique in the cases operated in our center, even though further investigations are necessary to fully examine this technique.

Do Chest Expansion Exercises Aid Re-shaping the Diaphragm Within the First 72 Hours Following Lung Transplantation in a Usual Interstitial Pneumonia Patient?

BACKGROUND AND PURPOSE: Usual interstitial pneumonia is a chronic pulmonary disease, and it is characterized by progressive and rapid lung fibrosis and typically affects patients older than 50 years. This study sought to discuss the use of chest expansion exercises during the immediate post-operative phase in a lung transplantation recipient. METHODS: This was a non-experimental case report study. A 58-year-old man who was affected by usual interstitial pneumonia with severe respiratory insufficiency requiring continuous oxygen therapy underwent double lung transplantation. Pre-operative x-ray showed elevation of the diaphragm. Rehabilitation treatment started within the first 24 h. Pain intensity was assessed using a numeric rating scale, and pulmonary function was evaluated based on variation in tidal volume. Each treatment lasted about 1 h, and the sessions were initially carried out twice daily, increasing over the intensive care unit stay to three or four times daily. RESULTS: At 72 h, the tidal volume increased to 850-900 mL (approximately 400 mL more than baseline) during the chest expansion exercises. The diaphragm began to gradually lower. Chest x-ray examination on post-operative day 6 showed further reshaping of the diaphragm. CONCLUSION: Chest expansion exercises seem to be suitable in order to re-establish lung volume and diaphragmatic function as early as within the first 72 h after bilateral lung transplantation.