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J Thorac Cardiovasc Surg 2007;133:1680-1681
© 2007 The American Association for Thoracic Surgery

Brief Communication

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

Masayoshi Inoue, MD, PhD*, Masato Minami, MD, PhD, Hajime Ichikawa, MD, PhD, Norihide Fukushima, MD, PhD, Hiroyuki Shiono, MD, PhD, Tomoki Utsumi, MD, PhD, Meinoshin Okumura, MD, PhD, Yoshiki Sawa, MD, PhD

Osaka University Graduate School of Medicine, Osaka, Japan.

Received for publication October 24, 2006; accepted for publication December 12, 2006.

* Address for reprints: Masayoshi Inoue, MD, PhD, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Osaka University Graduate School of Medicine, E1-2-2 Yamadaoka Suita-city, Osaka 565-0871, Japan. (Email: masa{at}surg1.med.osaka-u.ac.jp).

Extracorporeal membrane oxygenation (ECMO) has been reported to be effective for posttransplant pulmonary dysfunction, which is occasionally fatal.1,2Go We report 2 cases with pulmonary arterial hypertension (PAH), who were successfully treated with ECMO with direct central cannulation for graft dysfunction after lung transplantation. We also provide details regarding our delayed chest closure procedure, which contributed to posttransplant management.

Clinical Summary

Patient 1
A female patient was diagnosed with PAH at the age of 7 years. Because hemoptysis was found, living donor lung transplantation was scheduled at age 11. The patient had a status of New York Heart Association (NYHA) IV and was treated with O2 2 L/min, epoprostenol (20 ng · kg–1 · min–1), and sildenafil (57 mg/d), as well as diuretics and anticoagulants. Her chest radiograph showed cardiomegaly with 62% of the cardiothoracic ratio (CTR). Ultrasound cardiography (UCG) revealed tricuspid valve regurgitation of 3/4. Pulmonary arterial pressure was measured as 103/50 (71) mm Hg with cardiac catheterization. The patient underwent living donor bilateral lobe lung transplantation from both of her parents. The cardiopulmonary bypass time was 404 minutes, and the ischemic times of the grafts were 262 minutes for the left and 215 minutes for the right due to the difficulty of the bronchial anastomosis. ECMO with direct central cannulation via the right atrium and ascending aorta was established for graft dysfunction (PaO 2 87 mm Hg at FIO 2 1.0). The edematous grafts did not fit well in the thorax of the recipient; therefore, the skin was temporally closed using a latex-free Esmarch bandage (Matsuyoshi Ika-Kikai, Tokyo, Japan) with a drape, a type of tourniquet used for orthopedic surgery (Figure 1). An improvement of pulmonary edema was seen in the chest radiograph. The patient was weaned from ECMO followed by delayed chest closure on postoperative day (POD) 4. The patient was discharged on POD 160.


Figure 1
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  		Figure 1. Patient 1. A, The thorax was temporally closed using an Esmarch bandage with ECMO via direct central cannulation. B, Chest radiograph after transplantation showing an extrathoracic pulmonary shadow.

 
PATIENT 2. A female patient was diagnosed with PAH at the age of 14 years. She underwent cadaveric bilateral lung transplantation at age 19. Her status was NYHA III and the treatment regimen was O2 4 L/min, epoprostenol (22 ng · kg–1 · min–1), sildenafil (40 mg/d), bosentan (125 mg/d), and digitalis, as well as diuretics and anticoagulants. Chest radiograph imaging showed congestive lungs and 58% CTR. UCG revealed moderate tricuspid valve regurgitation, with a calculated systolic pulmonary arterial pressure of 78 mm Hg. The predictive vital capacity ratio of the donor/recipient was 107%. The cardiopulmonary bypass time was 399 minutes. The ischemic times of the grafts were 481 minutes for the left and 487 minutes for the right. The hilar adhesion in the recipient contributed to such excessive ischemic time. Because primary graft dysfunction was found (SaO 2 75% at FIO 2 1.0), we applied ECMO with direct central cannulation. The thoracic cavity was left open and the skin was closed using an Esmarch bandage in the same manner as in patient 1. After improvement of the pulmonary edema and the graft function (Figure 2), ECMO was discontinued and the chest was closed with partial resection of both lungs on POD 2. Weaning of mechanical ventilation was successfully completed by POD 9, and the patient was discharged on POD 73.


Figure 2
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  		Figure 2. Patient 2. A, Chest radiograph just after lung transplantation showing the oversized grafts forced out from the thoracic cavity. B, Chest radiograph taken prior to delayed chest closure. Pulmonary edema was improved and reduced into the thorax after ECMO support for 2 days.

 
Discussion

Patients with PAH show an alteration of cardiac morphology; thus, an unstable cardiopulmonary status is occasionally experienced after lung transplantation. It has been reported that perioperative support with ECMO is effective to prevent barotraumatic mechanical ventilation during posttransplant management.1,2Go We performed venoarterial ECMO to maintain sufficient systemic blood flow because cardiac failure caused by a hypoplastic left ventricle was predicted. Venovenous ECMO with fewer complications has been presented as an option for patients with normal cardiac function.3Go The patients presented here experienced rapid improvement of the edematous grafts with stable circulation with the use of venoarterial ECMO.

We chose direct central cannulation for ECMO because of the small-sized femoral vessels and the decision to perform a delayed chest closure. Femoral venoarterial ECMO may lead to an insufficient supply of oxygen to the proximal artery in patients with poor development of the femoral vessels.4Go Because we had no trouble with the central cannulated sites, direct cannulation was an effective option.

Delayed chest closure after lung transplantation was recently reported to be feasible, with no infection or survival difference found as compared with patients who underwent primary closure.5Go In cases presented here, an unnecessary pulmonary resection was avoided in patient 1 and reduction of resected lungs was achieved in patient 2. In addition, we found that utilization of the Esmarch bandage with use of a drape was effective for skin closure.

In conclusion, ECMO support with direct central cannulation followed by delayed closure was found to be useful for posttransplant treatment of graft dysfunction.

References

  1. Mason DP, Boffa DJ, Murthy SC, Gildea TR, Budev MM, Mehta AC, et al. Extended use of extracorporeal membrane oxygenation after lung transplantation. J Thorac Cardiovasc Surg 2006;132:954-960.[Abstract/Free Full Text]
  2. Meyers BF, Sudent 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]
  3. Hartwig MG, Appel 3rd JZ, Cantu 3rd E, Simsir S, Lin SS, Hsieh CC, et al. Improvement results treating lung allograft failure with venovenous extracorporeal membrane oxygenation. Ann Thorac Surg 2005;80:1879-1880.
  4. 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]
  5. Force SD, Miller DL, Pelaez A, Ramirez AM, Vega D, Barden B, et al. Outcome of delayed chest closure after bilateral lung transplantation. Ann Thorac Surg 2006;81:2020-2025.[Abstract/Free Full Text]




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