Impact of extracorporeal life support on outcome in patients with idiopathic pulmonary arterial hypertension awaiting lung transplantation

doi:10.1016/j.healun.2011.03.002

The Journal of Heart and Lung Transplantation

Volume 30, Issue 9, September 2011, Pages 997-1002

https://doi.org/10.1016/j.healun.2011.03.002 Get rights and content

Background

Our management of patients with idiopathic pulmonary arterial hypertension (iPAH) awaiting lung transplantation changed in 2006 with the introduction of extracorporeal life support (ECLS) as an option to bridge these patients to transplantation (BTT).

Methods

To study the effect of this change on waiting list mortality and post-transplant outcome, 21 consecutive iPAH patients listed for lung transplantation between January 2006 and September 2010 (second cohort) were compared with 23 consecutive iPAH patients listed between January 1997 and December 2005 (first cohort).

Results

Between the first and second cohort, the number of patients admitted to the hospital as BTT increased from 4% (1 of 23) to 48% (10 of 21; p = 0.0009). Six patients were BTT with ECLS in the second cohort, including 4 with the Novalung device (Novalung GmbH, Hechingen, Germany) connected as a pumpless oxygenating right-to-left shunt between the pulmonary artery and left atrium. While on the waiting list, 5 patients (22%) died in the first cohort and none in the second cohort (p = 0.03). Time on the waiting list decreased from 118 ± 85 to 53 ± 40 days between the first and second cohort (p = 0.004). After lung transplantation, the 30-day mortality was 16.7% in the first cohort and 9.5% in the second cohort (p = 0.5). The postoperative intensive care unit stay increased from 17 ± 13 to 36 ± 30 days between the first and second cohort (p = 0.02). The long-term outcome after lung transplantation remained similar between both cohorts.

Conclusions

Aggressive management with ECLS of iPAH patients awaiting lung transplantation could have a major impact to reduce the waiting list mortality. This may, however, be associated with longer intensive care unit stay after transplant.

Section snippets

Material and methods

All iPAH patients listed for lung or heart-lung transplantation in our program between January 1997 and September 2010 were retrospectively reviewed after the University Health Network Research Ethics Board approved the study and waived the need for informed consent. Patients with familial or anorexigen PAH were included in the study. However, the study excluded patients with PAH associated with connective tissue disorders or congenital heart disease because they often present with systemic

Results

Of 123 iPAH patients referred for lung transplantation since 1997, 44 were listed. The 23 patients who were listed between January 1997 and December 2005 were the first cohort, and the 21 patients listed between January 2006 and September 2010 were the second cohort. The number of patients referred and listed were similar between the first and the second cohort: 23 listed of 69 referrals (33%) vs 21 listed of 54 referrals (39%), respectively; (p = 0.5). Almost all patients were treated with

Discussion

This study suggests that an aggressive management strategy for patients with iPAH on the waiting list can decrease the waiting list mortality rate without increasing the postoperative risk for severe PGD or the 30-day mortality rate. We believe that the use of the Novalung between the PA and LA is an excellent option to bridge iPAH patients to lung transplantation because it provides an oxygenated, low-resistance right-to-left shunt and effectively unloads the RV. Patients can be weaned from

Disclosure statement

Novalung supported a clinical trial for lung transplant candidates at the Toronto General Hospital.

Dr de Perrot received speaking fees from Actelion. None of the other authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose.

Presented as an oral presentation at the Thirtieth Meeting of the International Society for Heart and Lung Transplantation, Chicago, Illinois, April 21–24, 2010.

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Featured articleImpact of extracorporeal life support on outcome in patients with idiopathic pulmonary arterial hypertension awaiting lung transplantation

Background

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Discussion

Disclosure statement

Chest

J Heart Lung Transplant

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am J Transplant

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

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Impact of extracorporeal life support on outcome in patients with idiopathic pulmonary arterial hypertension awaiting lung transplantation