Use of Extracorporeal Membrane Oxygenation (ECMO) After Surgery: Management of Primary Graft Dysfunction (PGD)

Since its first application more than 40 years ago, extracorporeal membrane oxygenation (ECMO) has emerged, with the improvement of biocompatible technologies, as a salvage option for patients in severe cardiopulmonary failure refractory to conventional management. ECMO has shown potential to improve outcomes in lung transplant recipients who develop severe primary graft dysfunction (PGD) refractory to standard supportive care. PGD is the syndrome of acute lung injury within 72 h from transplantation and it represents one of the most common causes of morbidity and mortality in lung transplant recipients. PGD is characterized by diffuse pulmonary infiltrates on radiological imaging and hypoxemia without other identifiable causes. Severe PGD (grade 3) is associated with high early mortality and requires complex management with a multidisciplinary team approach. Peripheral veno-venous (VV) ECMO is the most common cannulation strategy. Patients presenting with pulmonary hypertension, right ventricular failure and hemodynamic instability will require full circulatory support with veno-arterial (VA) ECMO. Cannulation is typically performed percutaneously under ultrasound guidance. After a few days of ECMO support, when cardiopulmonary function is recovered, the patient can be managed to be weaned off the ECMO circuit. Earlier initiation of ECMO has been associated with better outcomes and in recent years ECMO has been used “prophylactically” in patients at high-risk of PGD development. Efficient ECMO implementation and appropriate choice of the cannulation strategy are crucial to avoid unrecoverable clinical deterioration and life-threatening complications and to achieve the best possible outcome in this complex patient population.