‘Favorable’ 5-year outcomes when ECMO used as bridge to lung transplantation
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Key takeaways:
- Odds for survival on ECMO to transplant went down if the patient had an older age at listing.
- Survival did not significantly differ based on when a patient was listed for transplantation in relation to ECMO use.
Five years after lung transplantation, adults bridged to extracorporeal membrane oxygenation while waiting for their transplant had “favorable survival,” according to results published in Respiratory Research.
Notably, this study population was older, and survival did not significantly differ based on when a patient was listed for transplantation in relation to ECMO cannulation, according to researchers.
“The use of ECMO as a bridge to lung transplant has expanded considerably over the last 2 decades, yet evidence-based selection criteria remain lacking, with significant practice variation across centers,” Jared A. Daar, MD, pulmonology and critical care fellow at Temple University Hospital, told Healio.
“Both older age (with no well-defined upper bound) and not yet being listed for transplant (‘bridge to decision’) are sometimes cited as reasons not to offer ECMO as a bridge to lung transplant in severely ill, hospitalized advanced lung disease patients,” Daar continued.
In a retrospective, single-center study, Daar and colleagues assessed 50 adults (median age, 63 years) listed for a lung transplant and bridged on ECMO from 2012 to 2017 to gauge survival and allograft function 5 years after transplantation.
“Given the large number of older and not previously listed lung transplant candidates bridged on ECMO at our center since 2012, we aimed to analyze our center’s unique experience caring for this complex patient population to assess the feasibility of ECMO bridge to transplant in these understudied subgroups,” Daar told Healio.
“We were able to report outcome data up to 5 years post-transplant, whereas most prior studies have been limited to 36 months,” Daar said.
Half of the total cohort received a transplant (median age at listing, 58 years), whereas the other half died before transplantation (median age at listing, 65 years).
“The study cohort ... is one of the oldest described in the literature,” Daar told Healio. “This included 32% of patients who were not previously listed at the time of ECMO cannulation and bridged to decision.”
In the group of patients who survived to transplant, 88% continued to survive 1 year after the procedure, according to the study.
“We found that 1-year post-transplant survival closely approximated the national rate for all adult lung transplant recipients, with quality of life evidenced by time spent at home (median, 340 days) in the year post-transplant,” Daar said.
By the 3-year mark, researchers reported that 60% of these patients were still alive, and by the 5-year mark, 44% continued to survive, both of which Daar told Healio were “favorable.”
In the patients alive at 3 years and 5 years, Daar highlighted “good allograft function and low rates of rejection” based on spirometry and surveillance transbronchial biopsy findings.
Researchers additionally found reduced odds for survival on ECMO to transplant if patients had an older age at listing (OR = 0.92; 95% CI, 0.86-0.99).
“The major barrier in this area, where high pre-transplant mortality on ECMO has been described by many centers, remains how best to select patients most likely to benefit from this high-risk bridging strategy,” Daar told Healio. “While the effect was small, our data suggest that older age may be a negative predictor of survival on ECMO to transplant, even though these patients do well once transplanted.”
Lastly, in an effort to see if survival following transplantation changes based on when a patient was listed for transplant in relation to ECMO cannulation, researchers evaluated the 10 patients placed on ECMO prior to listing vs. the 15 patients already listed when placed on ECMO. Survival did not significantly differ between the two groups, and Daar said this is “one of the most notable findings.”
“We hope this study provides additional insight to transplant centers weighing difficult decisions about ECMO candidate selection and management,” Daar told Healio.
Importantly, Daar said caution is needed when generalizing these findings due to study design.
“A broader effort is necessary to identify characteristics of advanced lung disease patients most likely to benefit from ECMO as a bridge to lung transplant, to ensure physicians across centers have optimal data to provide the best possible care to this complex patient population,” Daar told Healio.
For more information:
Jared A. Daar, MD, can be reached at jared.daar@tuhs.temple.edu.