Extended use of central veno-arterial extracorporeal membrane oxygenation in lung transplantation for patients with pulmonary arterial hypertension

OBJECTIVES Lung transplantation (LTx) for patients with pulmonary arterial hypertension (PAH) is associated with high postoperative morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) supports patients’ haemodynamics during and after LTx. However, the optimal ECMO strategy, especially for patients with PAH, is debated. Here, we report our unique strategy for patients with PAH, using postoperative central veno-arterial (VA)-ECMO combined with delayed chest closure. METHODS This was a retrospective single-center study of consecutive bilateral lung transplantations for adult patients with PAH performed between 2021 and 2024. Patients’ characteristics, perioperative ECMO strategy, and postoperative outcomes were reviewed. RESULTS During the study period, 20 PAH patients (idiopathic or hereditary PAH [n = 17], PAH secondary to collagen disease [n = 1], pulmonary veno-occlusive disease [n = 1], and Eisenmenger syndrome [n = 1]) underwent cadaveric LTx. Intraoperative support comprised either central VA-ECMO (n = 17) or cardiopulmonary bypass (n = 3). In 17 patients, central VA-ECMO was maintained postoperatively with temporary skin closure. The reason for postoperative central VA-ECMO was anticipated post-LTx heart failure due to PAH and suboptimal cardiac function. The median duration of ECMO support was 4 days (interquartile range: 2–4). There were 9 (45.0%) haemothorax evacuations while patients were on postoperative central VA-ECMO. No patients experienced haemodynamic collapse after LTx. All patients survived during the observation period, resulting in a 100% survival rate at both 90 days and 1 year (95% confidence interval: 83.2%–100%). CONCLUSIONS Extended postoperative central VA-ECMO and delayed chest closure were feasible for patients with PAH who underwent LTx. Meticulous haemostasis is mandatory, given the high chance of haemothorax evacuation.