Veno-Arterial-Venous ECMO in Severe Primary Lung Graft Dysfunction, a Retrospective Monocenter Study

Purpose Primary graft dysfunction (PGD) occurs in about 20-35% of lung transplantations (LT), with a mortality rate approaching 50% in grade 3 PGD. The treatment remains symptomatic with reports showing favorable survival rates when ECMO is used intra- and postoperatively. It exists two classical configurations, Veno-Venous (VV) and Veno-Arterial (VA) ECMO, with the former providing respiratory support, and the latter giving an additional hemodynamic one. The aim is to highlight the use and results of Veno-Arterial-Venous (VAV) ECMO in the management of Grade 3 PGD, as it combines the benefits of both types. Methods We performed a single-centre retrospective study based on our institutional database. In our VAV ECMO setting, the drainage cannula is placed in the femoral vein, while reinfusion cannulas are put in the femoral artery and the internal jugular vein. Flow is monitored using sensors, and regulated using a screw clamp on the reinfusion venous line. Our protocol is to wean the arterial cannula first when the patients become hemodynamically stable, then VV ECMO once respiratory support is longer required. Results Between April 2016, and April 2020, a total of 280 patients were transplanted at our center. 125 patients needed circulatory assistance intraoperatively. Of those, ECMO was maintained in 65 cases postoperatively (group 1). While 7 patients without intraoperative ECMO, required it during the postoperative 72 hours (group 2). VAV ECMO was used in a total of 8 patients, 6 belonging to group 1, and 2 to group 2. Median age was 40,8 [29,0-56,6] years All of the patients underwent bilateral LT with one patient having a combined liver transplantation as well. The indication of LT was cystic fibrosis in n=5, Idiopathic pulmonary fibrosis in n=2, and re-transplantation for chronic rejection in n=1. The arterial cannula was kept for a median of 5 [3-5] days, while total ECMO weaning was done at a median of 9 [6-17,25]. days. Median ventilation duration was 22 [8-29]. 2 patients died, while the other 6 patients are alive and well up to the date of the abstract. Conclusion VAV ECMO can safely be applied in case of severe refractory hypoxemia despite a VA ECMO in grade 3 PGD patients after LT. It provides a bridge to progressive weaning, with encouraging survival rates. However, more data is needed for further evaluation.