Bilateral lung transplantation with intra- and postoperatively prolonged ECMO support in patients with pulmonary hypertension.

OBJECTIVE: Lung transplantation for pulmonary hypertension (PH) is usually performed on cardiopulmonary bypass, with the disadvantage of full systemic anticoagulation, uncontrolled allograft reperfusion and aggressive ventilation. These factors can be avoided with intra- and postoperatively prolonged extracorporeal membrane oxygenator (ECMO) support. PATIENTS AND METHODS: Between February 1999 and March 2001, 17 consecutive patients with PH (systolic pulmonary artery pressure >70 mmHg) of different etiologies underwent bilateral lung transplantation (BLTX). There were 11 females and six males in the age range from 7 to 50 years (mean age, 28.4+/-12.9 years). Six patients were preoperatively hospitalized, four in the intensive care unit (ICU), one was on ECMO for 3 weeks pretransplantation, and one was resuscitated and bridged with ECMO for 1 week until transplantation. Femoral venoarterial ECMO support with heparin-coated circuits was set up after induction of anesthesia and discontinued at the end of surgery (n=3) or extended for 12 h median into the postoperative period (n=14). Postoperative ventilation pressure was kept below 25 mmHg. Allograft function at 2 h after discontinuation of ECMO, outcome and adverse events were monitored in all patients. Mean follow up time was 18+/-11.4 months. RESULTS: The perioperative mortality was 5.9% (n=1). Arterial oxygen pressure measured 2 h after weaning from ECMO, and under standard mechanical ventilation with a peak pressure of 25 mmHg and inspired oxygen fraction of 0.4, was 157+/-28 mmHg. The mean pulmonary artery pressures were reduced to 29+/-3,4 from 66+/-15 mmHg before transplantation. Postoperative complications included rethoracotomy due to bleeding (n=4) and temporary left ventricular failure (n=4). Median ICU stay was 12 days. Incidence of rejection within the first 100 days was 0.4 per patient. CONCLUSION: BLTX with intraoperative and postoperatively prolonged ECMO support provides excellent initial organ function due to optimal controlled reperfusion and non-aggressive ventilation. This results in improved outcome even in advanced forms of PH.

The value of switching from cyclosporine to tacrolimus in the treatment of refractory acute rejection and obliterative bronchiolitis after lung transplantation.

Standard cyclosporine-based immunosuppression is ineffective in the treatment of refractory acute rejection (RAR) and obliterative bronchiolitis (OB) that follows lung transplantation. The aim of this study was to evaluate the results of switching from cyclosporine to tacrolimus in the treatment of these situations. Nineteen patients entered the study. The indication for switching was OB in 11 patients and RAR in 8. Mean age was 41.3 +/- 13.1 years. In patients with RAR, the number of acute rejections was 1.5 +/- 0.7 and there were zero episodes per patient per 100 days before and after switching, respectively ( P = 0.02). There was no significant reduction of the decline of forced expiratory volume (FEV(1)) within 6 months after switching in patients with OB. We conclude that the conversion from cyclosporine to tacrolimus was associated with favourable results in the treatment of RAR. Further studies are required to assess the influence of this approach in the treatment of OB.