JTCS Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
David P. Mason
Daniel J. Boffa
Sudish C. Murthy
Nicholas G. Smedira
Thomas W. Rice
Eugene H. Blackstone
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mason, D. P.
Right arrow Articles by Pettersson, B. G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mason, D. P.
Right arrow Articles by Pettersson, B. G.

J Thorac Cardiovasc Surg 2006;132:954-960
© 2006 The American Association for Thoracic Surgery

Cardiothoracic Transplantation

Extended use of extracorporeal membrane oxygenation after lung transplantation

David P. Mason, MDa,*, Daniel J. Boffa, MDa, Sudish C. Murthy, MD, PhDa, Thomas R. Gildea, MDb, Marie M. Budev, DOb, Atul C. Mehta, MDb, Ann M. McNeill, RNa, Nicholas G. Smedira, MDa, Jingyuan Feng, MSc, Thomas W. Rice, MDa, Eugene H. Blackstone, MDa,c, B. Gösta Pettersson, MD, PhDa

a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
b Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
c Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.

Received for publication March 23, 2006; revisions received June 14, 2006; accepted for publication June 20, 2006.

* Address for reprints: David P. Mason, MD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave/Desk F24, Cleveland, OH 44195. (Email: masond2{at}ccf.org).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 Conclusions
 Appendix
 References
 
Objectives: Extracorporeal membrane oxygenation (ECMO) for severe graft failure after lung transplantation is accepted immediately postoperatively; extending its use is controversial. We evaluated our post–lung transplant ECMO experience, which included extended indication, to (1) determine its prevalence, risk factors, indications, and timing, (2) compare complications and outcomes of these patients with those not requiring it, and (3) identify risk factors, including indications, for mortality.

Methods: From February 1990 to October 2005, 474 patients underwent lung transplantation; postoperative ECMO support was instituted for severe graft failure 23 times in 22 patients (4.0%). Indications for ECMO and its timing were obtained by reviewing medical records and survival by systematic follow-up.

Results: No factor evaluated predicted severe graft failure leading to ECMO. The most common indication for ECMO was early graft failure (13 patients); however, it was also used for pneumonia or sepsis (6) and acute rejection (4). ECMO was initiated at a median arterial oxygen tension/inspired oxygen fraction of 59 at a median of 2 days postoperatively and was maintained for a median of 4 days. The most common complications were renal failure (57%) and bleeding (43%). ECMO was effective in salvaging patients with rejection and early graft failure (survival at 1, 3, 6, and 12 months: 62%, 54%, 49%, and 41%), but ineffective for pneumonia or sepsis (survival at these intervals: 9%, 4%, 4%, and 3%).

Conclusions: ECMO can be extended beyond early severe graft failure to acute rejection and can be considered after the immediate postoperative period. Survival after ECMO in patients with pneumonia or sepsis is poor.

Abbreviations and Acronyms ECMO = extracorporeal membrane oxygenation; PRA = panel reactive antibody; VA = venoarterial; VV = venovenous


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 Conclusions
 Appendix
 References
 
Severe graft failure, characterized by impaired gas exchange, is uncommon after lung transplantation but carries high mortality.1Go Extracorporeal membrane oxygenation (ECMO) may be necessary to provide lifesaving support when maximal conventional therapy for cardiorespiratory support is inadequate to maintain oxygenation and perfusion.2Go Survival after ECMO depends on indication, technique, and timing.3–5Go Furthermore, although ECMO is now accepted for severe, immediate postoperative graft failure, extending its use to other indications is controversial. Therefore, to guide future use, we evaluated our experience with post–lung transplant ECMO, which includes extended indications, to (1) determine its prevalence, risk factors, indications, and timing, (2) compare complications and outcomes of these patients with those not requiring it, and (3) identify risk factors, including indications, for mortality.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 Conclusions
 Appendix
 References
 
Patients
From February 1990 to October 2005, 474 patients underwent single or double lung transplantation for end-stage lung disease at Cleveland Clinic. Data were extracted from the Unified Transplant Registry, which has been approved for research by the Institutional Review Board of Cleveland Clinic. The Institutional Review Board approved supplemental review of medical records.

ECMO
Support
ECMO was initiated 23 times in 22 patients (4.0%), when oxygenation, ventilation, and tissue perfusion were unable to be supported through conventional methods, including ventilator support with 100% inspired oxygen fraction, pharmacologic paralysis, nitric oxide, high positive end-expiratory pressure, and vasopressors. Median arterial oxygen tension/inspired oxygen fraction was 59 at institution of ECMO (15th and 85th percentiles, 44 and 81), which improved to 164 after ECMO was initiated (15th and 85th percentiles, 81 and 443). Cannulation was peripheral in 20 cases (87%), central in 2 (9%), and combined in 1 (4%). ECMO technique was venoarterial (VA) in 12 (52%) and venovenous (VV) in 11 (48%), based on surgeon preference. As a general rule, VA ECMO was used to support patients with hemodynamic collapse in addition to respiratory failure, and VV ECMO was used for all other patients, without regard to pulmonary artery pressures. Median pulmonary artery systolic pressure was 49 mm Hg at institution of ECMO (15th and 85th percentiles, 27 and 66 mm Hg), which improved to 37 mm Hg after ECMO was initiated (15th and 85th percentiles, 25 and 49 mm Hg).

Circuit
The ECMO circuit has been described previously.6Go In brief, peripheral or central access was established via wire-reinforced thin-walled polyurethane cannulas (Edwards LifeSciences, Irvine, Calif). The circuit was driven by a centrifugal pump (BP80, Medtronic-BioMedicus, Eden Prairie, Minn) through heparin-coated tubing (Carmeda, Medtronic) and either a hollow-fiber oxygenator (AFFINITY NT, Medtronic) or Maxima-Plus PRF oxygenator (Medtronic) before its discontinuation. All components were heparin coated. Four peripheral cannulas were placed percutaneously, with the remainder being placed by cutdown. Sizes ranged from 16F to 24F. Distal arterial cannulation was used in 2 patients.

Conduct
Systemic heparinization was used with a target activated clotting time of 180 to 250 seconds. Flows were maintained between 2.5 and 3.5 L · min–1. Decision to wean from ECMO was based on radiographic improvement, improved oxygenation, increased graft compliance, and improved hemodynamics.

Risk Factors for Severe Graft Failure Leading to ECMO
Multivariable logistic regression was used for identifying donor and recipient variables (Appendix) associated with ECMO. The process began with initial screening to ensure that at least 5 ECMO events were associated with each dichotomous variable.

Bootstrap aggregation (bagging) was used for variable selection.7,8Go In brief, automated stepwise variable selection with P for inclusion of .1 was performed on 1000 bootstrap samples, and the results were aggregated both by individual factors and by clusters of related factors (such as candidate transformations of scale of continuous and ordered variables). Those appearing in 50% or more of the analyses (median rule) were considered reliably statistically significant at P ≤ .1.

Etiology of Graft Failure Necessitating ECMO
Chart review, review of cultures, biopsy tissues, and clinical impressions of the lung transplant team at time of instituting ECMO were used to categorize etiology of graft failure as follows: (1) early graft failure, if failure occurred within the first 48 hours of transplant and was due to either an implantation response or a technical problem that was identified and corrected; (2) acute rejection, if there was a clinical impression of rejection driving graft failure, usually documented by transbronchial biopsies; or (3) pneumonia or sepsis, if the clinical impression of the transplant team was infection driving graft failure, with the criteria being purulent bronchoscopy, positive cultures, fever, and leukocytosis.

Timing and Duration of ECMO
Timing of ECMO was calculated as interval from date of operation to date of instituting ECMO. Duration of ECMO was calculated as interval from date of instituting ECMO until its removal or death on ECMO.

Outcomes
Primary outcome was all-cause mortality. Vital status was obtained by cross-sectional follow-up. Mean follow-up duration was 0.73 ± 1.2 years, with 5 of 22 patients (23%) followed for more than 1 year. A total of 16.7 patient-years of data was available for analysis. Survival estimates after ECMO were obtained by the Kaplan-Meier method and a parametric multiphase survival model.9Go Secondary outcomes were in-hospital complications of ECMO.

Predictors of Mortality
Eight variables were used to identify predictors of mortality after ECMO: (1) date of transplant, (2) single versus double lung transplant, (3-5) etiology of severe graft failure (early graft failure, acute rejection, pneumonia, or sepsis), (6) timing of ECMO, (7) VA versus VV cannulation, and (8) duration of ECMO. Variable selection was as previously described.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 Conclusions
 Appendix
 References
 
Risk Factors for Severe Graft Failure Leading to ECMO
We were unable to identify reliably either recipient or donor demographic, pretransplant clinical, or transplant variables that predicted severe graft failure leading to ECMO (Table 1). Variables not found to be associated with severe graft failure included cold ischemic time, panel reactive antibody (PRA) level, and donor-to-recipient size match.


View this table:
[in this window]
[in a new window]

  		TABLE 1. Recipient, donor, and transplant characteristics for ECMO and no-ECMO groups
 
Etiology of Graft Failure Necessitating ECMO
The most common indication for ECMO was early graft failure (n = 13, 57%), followed by pneumonia or sepsis (n = 6, 26%) and acute rejection (n = 4, 17%). Three patients with early graft failure had left atrial anastomotic complications that caused pulmonary congestion and necessitated reoperation. Another had important bleeding from dense pleural adhesions that led to high transfusion requirement and multiple reoperations. All others (n = 9) had severe graft failure of unclear etiology that could be termed "primary graft dysfunction"10Go; we elected to use the term "early graft failure," however, because of the unclear etiology yet early temporal relationship to transplantation. Three patients required ECMO for acute rejection, with 1 of the 3 requiring 2 separate ECMO runs. Acute rejection was diagnosed by transbronchial biopsy and treated with plasmapheresis and antithymocyte globulin. No patient underwent acute retransplantation.

Timing and Duration of ECMO
ECMO was initiated at a median of 2 days postoperatively (range, 0-21 days; 15th and 85th percentiles, 0 and 12 days; Figure 1). It was instituted earliest for severe graft failure (generally within 2 days of lung transplant), was instituted over a broad range of timing for pneumonia or sepsis, but generally later than for severe graft failure, and was concentrated within the second week for acute rejection. ECMO was maintained for a median of 4 days (range, 2-17 days; 15th and 85th percentiles, 3 and 10 days; Figure 2). Median duration was longest in the pneumonia/sepsis group (7 days; P [Wilcoxon] for differences among groups = .03). VA and VV ECMO were similarly effective in reducing pulmonary artery pressures.


Figure 1
View larger version (11K):
[in this window]
[in a new window]

  		Figure 1. Relation of indication for ECMO and its timing (interval from lung transplant to institution of ECMO). ECMO, extracorporeal membrane oxygenation.

 

Figure 2
View larger version (11K):
[in this window]
[in a new window]

  		Figure 2. Duration of ECMO according to etiology. ECMO, extracorporeal membrane oxygenation.

 
Complications of ECMO
Twenty of 22 patients (90%) had at least 1 complication directly attributable to ECMO (Table 2). The most commonly occurring complications were renal failure necessitating dialysis (57%) and bleeding necessitating reoperation (43%). Complications occurred with both VA and VV ECMO, with similar prevalence (P = .5). Complications were associated with both peripheral and central cannulation techniques, although the small number of central cannulations (2) precluded meaningful comparison. There were no deep vein thromboses in either patient cannulated centrally.


View this table:
[in this window]
[in a new window]

  		TABLE 2. ECMO complications (n = 23 among 22 patients)
 
Survival After ECMO
We compared survival after ECMO against survival of all other patients undergoing lung transplantation at Cleveland Clinic between February 1990 and October 2005 (Figure 3, A). Initially, risk of death was substantially higher in the ECMO group, but patients surviving beyond 1 year had a risk of death not importantly different from that of those not placed on ECMO (Figure 3, B).


Figure 3
View larger version (13K):
[in this window]
[in a new window]

  		Figure 3. Death after ECMO (open circles) and death in all others after lung transplant (closed circles). A, Survival. Each circle represents a death, vertical bars are asymmetric 68% confidence intervals for these estimates (equivalent to ±1 standard error), and numbers in parentheses represent patients alive at various time points. Solid lines represent parametric estimates enclosed within 68% confidence limits. B, Hazard function (instantaneous risk of death), ECMO, extracorporeal membrane oxygenation.

 
Predictors of Mortality
Of the 8 variables evaluated, the only 1 associated with worse outcome was instituting ECMO for pneumonia or sepsis (Figure 4). Survival was similar in patients supported for acute rejection and early graft failure.


Figure 4
View larger version (9K):
[in this window]
[in a new window]

  		Figure 4. Survival after ECMO according to indication for ECMO. Format is similar to that of Figure 3, A, except closed circles represent ECMO for early graft failure and acute rejection, and open circles represent ECMO for pneumonia or sepsis, ECMO, extracorporeal membrane oxygenation.

 

   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
Conclusions
 Appendix
 References
 
Most transplant centers perform ECMO for severe early graft failure (within 48 hours of transplant), because there is an impression that outcomes are poor for other indicators. Our study focused on patients supported with ECMO beyond the early postoperative period and for extended indications.

Principal Findings
Risk factors for severe graft failure leading to ECMO
We were unable to identify risk factors for severe graft failure leading to ECMO after lung transplantation. This may be because graft failure severe enough to require ECMO was uncommon, with a prevalence of only 4%. We were not able to reproduce results of others showing that recipient diagnosis of primary pulmonary hypertension, mismatch of donor and recipient size, or female gender were predictive of need for ECMO.4,11,12Go Although PRA levels have been shown to be predictive of survival after lung transplantation,13Go they were not predictive of need for ECMO.

Etiology of graft failure necessitating ECMO
As in other studies, early graft failure was the most common indication for ECMO in our patients, followed by pneumonia or sepsis. We agree with the movement to standardize the term "primary graft dysfunction" to define lung injury occurring after graft implantation10Go and are incorporating this term prospectively. However, in this study, we used the term "early graft failure" because of our difficulty differentiating the role of transfusion requirement and pulmonary venous complications leading to ECMO in 3 patients.

Timing and duration of ECMO
Our median timing overall of initiating ECMO, postoperative day 2, was slightly later than recently reported series in which ECMO was almost universally initiated within the first 2 days of transplant.12,14Go However, this relates at least in part to our extended use of ECMO that, in comparison, resulted in instituting ECMO over a wide range of postoperative days, with the latest being day 21. We have confirmed that patients can still be salvaged when placed on ECMO later in their hospital course, particularly those experiencing acute rejection, although numbers are small.15Go In addition, we have shown that survival is possible in patients who require longer periods of ECMO support, with 1 patient being discharged alive from the hospital after 17 days on ECMO.

Complications of ECMO
Nearly all our patients had complications directly attributable to ECMO. Complications seem inherent in the ECMO circuit, primarily because it requires large cannulas that are thrombogenic despite their heparin coating and that can lead to distal limb malperfusion and thromboembolism. In addition, need for anticoagulation to prevent or treat thromboembolism, as well as hemolysis resulting from the ECMO circuit, predispose patients with fresh operative fields to bleeding. Bleeding complications were not directly related to level of anticoagulation and occurred in the face of normal thrombocyte counts.

We have become increasingly aggressive about diagnosing and treating deep vein thrombosis and use inferior caval filters after decannulation when proximal deep vein thrombosis has been identified. Dialysis requirement reflects multifactorial injury to the kidneys that occurs secondarily to hemodynamic instability, vasopressor use, sepsis, direct effects of the ECMO circuit, and effects of multiple nephrotoxic drugs. Although multiple antibiotics were used to treat sepsis, we did not alter our routine postoperative antifungal therapy as prophylaxis for patients on ECMO.

Survival after ECMO
Survival after ECMO was reasonable and consistent with that of other reports, with salvage possible in a group of patients who would otherwise have died. Survival was best in patients treated for early graft failure and acute rejection. Interestingly, hazard curves for patients needing ECMO versus those who did not became equivalent at 1 year, suggesting that initial factors leading to ECMO and the ensuing difficult postoperative course can be overcome without affecting long-term survival.

Predictors of mortality
Of the 8 variables evaluated as predictors of mortality for patients requiring ECMO (Figure 3), we were able to identify only 1: institution of ECMO for sepsis or pneumonia. Other studies have suggested that VV was preferable to VA ECMO,12Go that the era in which ECMO was instituted was a risk factor,3Go and that instituting ECMO late (>7 days) after transplant was almost never successful.5Go Our multivariable analysis did not identify any of these factors as predictors of mortality, although this may be due to small numbers and confounding of multiple variables (for example, timing of ECMO and etiology of graft failure leading to ECMO). Our study does support Meyers and colleagues'4Go finding that outcomes were poor after ECMO use in infected patients. Although our study showed similar outcomes of VA and VV ECMO, we have gravitated toward use of VV even in the setting of pulmonary hypertension and hemodynamic compromise. Correction of acidosis, carbon dioxide clearance, and improved oxygenation provided by the VV circuit rapidly lower pulmonary artery pressures and improve systemic hemodynamics. We reserve VA ECMO for patients with high vasopressor requirements and imminent circulatory arrest.

Limitations
The primary limitation of this study is that it represents clinical experience at a single center with low prevalence of severe graft failure leading to ECMO. In addition, diagnosing early graft failure, acute rejection, and pneumonia or sepsis can be difficult, and etiology may be multifactorial. Biopsy in the setting of severe hypoxia or anticoagulation is frequently not possible, and positive cultures can represent colonization as well as active infection. In addition, the criteria for VA versus VV ECMO were not well defined and were influenced by multiple factors, including hemodynamics, surgeon preference, and era of transplantation.


   Conclusions
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 Conclusions
Appendix
 References
 
Our study has shown that ECMO can be used with reasonable results to salvage patients with severe graft failure after lung transplantation. We have learned to consider carefully all patients with severe graft failure for ECMO and to extend its use selectively past the initial perioperative period, particularly to those with acute rejection.


   Appendix
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 Conclusions
 Appendix
References
 
Variables Used in Analyses

Recipient
Demographic
Gender, age (years), height (cm), weight (kg), body surface area (m2), body mass index (kg · m–2)

Diagnosis
Chronic obstructive pulmonary disease, emphysema, cystic fibrosis, idiopathic pulmonary fibrosis, hypertension

Immunology
Blood type, PRA level (%)

Transplant
Single, double; ischemic time (min); interval from January 1, 1990 to index surgery

Donor
Demographic
Gender, age (years), height (cm), weight (kg), body surface area (m2), body mass index (kg · m–2)

Immunology
Blood type

Cause of death
Cerebral bleeding, cardiovascular accident, head trauma

Comorbidity
Hypertension

Donor–Recipient
Demographic
Difference in body mass index (recipient – donor), body mass index ratio (recipient/donor), difference in body surface area (recipient – donor), body surface area ratio (recipient/donor)

ECMO
VV versus VA cannulation


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 Conclusions
 Appendix
 References
 

  1. Christie JD, Kotloff RM, Ahya VN, Tino G, Pochettino A, Gaughan C, et al. The effect of primary graft dysfunction on survival after lung transplantation. Am J Respir Crit Care Med 2005;171:1312-1316.[Abstract/Free Full Text]
  2. Glassman LR, Keenan RJ, Fabrizio MC, Sonett JR, Bierman MI, Pham SM, et al. Extracorporeal membrane oxygenation as an adjunct treatment for primary graft failure in adult lung transplant recipients. J Thorac Cardiovasc Surg 1995;110:723-726discussion 6-7.[Abstract/Free Full Text]
  3. Oto T, Rosenfeldt F, Rowland M, Pick A, Rabinov M, Preovolos A, et al. Extracorporeal membrane oxygenation after lung transplantation: evolving technique improves outcomes. Ann Thorac Surg 2004;78:1230-1235.[Abstract/Free Full Text]
  4. Meyers BF, Sundt 3rd TM, Henry S, Trulock EP, Guthrie T, Cooper JD, et al. Selective use of extracorporeal membrane oxygenation is warranted after lung transplantation. J Thorac Cardiovasc Surg 2000;120:20-26.[Abstract/Free Full Text]
  5. Nguyen DQ, Kulick DM, Bolman 3rd RM, Dunitz JM, Hertz MI, Park SJ. Temporary ECMO support following lung and heart-lung transplantation. J Heart Lung Transplant 2000;19:313-316.[Medline]
  6. Smedira NG, Moazami N, Golding CM, McCarthy PM, Apperson-Hansen C, Blackstone EH, et al. Clinical experience with 202 adults receiving extracorporeal membrane oxygenation for cardiac failure: survival at five years. J Thorac Cardiovasc Surg 2001;122:92-102.[Abstract/Free Full Text]
  7. Breiman L. Bagging predictors. Machine Learning 1996;24:123-140.
  8. Blackstone EH. Breaking down barriers: helpful breakthrough statistical methods you need to understand better. J Thorac Cardiovasc Surg 2001;122:430-439.[Free Full Text]
  9. Blackstone EH, Naftel DC, Turner Jr ME. The decomposition of time-varying hazard into phases, each incorporating a separate stream of concomitant information. J Am Stat Assoc 1986;81:615-624.
  10. Christie JD, Carby M, Bag R, Corris P, Hertz M, Weill D. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction part II: definition. A consensus statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2005;24:1454-1459.[Medline]
  11. Meyers BF, de la Morena M, Sweet SC, Trulock EP, Guthrie TJ, Mendeloff EN, et al. Primary graft dysfunction and other selected complications of lung transplantation: a single-center experience of 983 patients. J Thorac Cardiovasc Surg 2005;129:1421-1429.[Abstract/Free Full Text]
  12. Hartwig MG, Appel 3rd JZ, Cantu 3rd E, Simsir S, Lin SS, Hsieh CC, et al. Improved results treating lung allograft failure with venovenous extracorporeal membrane oxygenation. Ann Thorac Surg 2005;80:1872-1879discussion 9-80.[Abstract/Free Full Text]
  13. Hadjiliadis D, Chaparro C, Reinsmoen NL, Gutierrez C, Singer LG, Steele MP, et al. Pre-transplant panel reactive antibody in lung transplant recipients is associated with significantly worse post-transplant survival in a multicenter study. J Heart Lung Transplant 2005;24:S249-S254.[Medline]
  14. Dahlberg PS, Prekker ME, Herrington CS, Hertz MI, Park SJ. Medium-term results of extracorporeal membrane oxygenation for severe acute lung injury after lung transplantation. J Heart Lung Transplant 2004;23:979-984.[Medline]
  15. Aigner C, Jaksch P, Mazhar S, Czebe K, Marta G, Taghavi S, et al. Treatment of severe acute lung allograft rejection with OKT3 and temporary extracorporeal membrane oxygenation bridging. Eur J Cardiothorac Surg 2004;25:184-187.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Eur. J. Cardiothorac. Surg.Home page
N. U. Khan, M. Al-Aloul, R. Shah, and N. Yonan
Early experience with the Levitronix Centrimag(R) device for extra-corporeal membrane oxygenation following lung transplantation
Eur. J. Cardiothorac. Surg., December 1, 2008; 34(6): 1262 - 1264.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
M. Berman, S. Tsui, A. Vuylsteke, A. Snell, S. Colah, R. Latimer, R. Hall, J. E. Arrowsmith, J. Kneeshaw, A. A. Klein, et al.
Successful Extracorporeal Membrane Oxygenation Support After Pulmonary Thromboendarterectomy
Ann. Thorac. Surg., October 1, 2008; 86(4): 1261 - 1267.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
M. Inoue, M. Minami, H. Ichikawa, N. Fukushima, H. Shiono, T. Utsumi, M. Okumura, and Y. Sawa
Extracorporeal membrane oxygenation with direct central cannulation followed by delayed chest closure for graft dysfunction after lung transplantation: Report of two cases with pulmonary arterial hypertension
J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1680 - 1681.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
David P. Mason
Daniel J. Boffa
Sudish C. Murthy
Nicholas G. Smedira
Thomas W. Rice
Eugene H. Blackstone
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Mason, D. P.
Right arrow Articles by Pettersson, B. G.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Mason, D. P.
Right arrow Articles by Pettersson, B. G.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS