Elective use of intraoperative extracorporeal membrane oxygenation in patients with pulmonary fibrosis reduces primary graft dysfunction after bilateral lung transplantation

OBJECTIVES This study presents the 5-year experience with a more liberal intraoperative extracorporeal membrane oxygenation (ECMO) elective support in patients with pulmonary fibrosis (PF) undergoing lung transplantation (LTx). METHODS Patients with PF undergoing LTx between 01.2012 and 01.2025 were included and sub-divided into the period before and after the implementation of a more liberal intraoperative use of ECMO support in 01.2020. Outcomes were compared between elective, non-elective and no intraoperative ECMO in both periods. Previously identified parameters as decision criteria for elective ECMO were examined. RESULTS Overall, 422 PF patients underwent LTx, of whom 273 patients were transplanted before 2020 (elective ECMO n = 52 (19%), non-elective ECMO n = 30 (11%), no ECMO n = 191 (70%)) and 149 patients were transplanted since 2020 (elective intraoperative ECMO n = 98 (66%), non-elective ECMO n = 12 (8%), no ECMO n = 39 (26%)). After 2020, elective ECMO was increasingly used in patients with mean pulmonary arterial pressure >50 mmHg and pulmonary vascular resistance >9.4 WU. However, 8% were not identified based on these parameters and still required non-elective ECMO. Comparing pre- and post-2020, primary graft dysfunction (PGD) grade 3 72-hours post-transplant between elective (17% vs 3%, p = 0.002), non-elective (38% vs 0%, p = 0.016) and no ECMO (12% vs 3%, p = 0.078) was significant reduced. One-year graft survival in elective (88.5% vs 95.6%), non-elective (70% vs 91.7%) and no ECMO (92.7% vs 94.9%) showed a trend towards improved survival. CONCLUSIONS The use of a more liberal, elective intraoperative ECMO support in patients with pulmonary fibrosis led to an improvement of PGD prevalence and survival early after lung transplantation.