Perioperative factors associated with intraoperative circulatory decompensation during lung transplantation under initial VV-ECMO support: an exploratory single-center study

Background Intraoperative circulatory decompensation during lung transplantation is a life-threatening event that often necessitates a challenging transition from veno-venous (VV) to veno-arterial (VA) extracorporeal membrane oxygenation (ECMO). This study evaluated perioperative variables associated with decompensation under an explicitly exploratory observational framework. Methods A retrospective analysis was conducted on 97 patients with end-stage lung disease undergoing lung transplantation with initial VV-ECMO support from January 2020 to December 2022. Intraoperative circulatory decompensation was redefined using objective hemodynamic and echocardiographic criteria; VV-to-VA conversion was recorded as a management consequence rather than as a defining criterion. Propensity score matching (PSM) was applied to balance confounding factors, resulting in 75 analyzed patients. Candidate models were revised as exploratory penalized models and internally assessed by repeated fivefold cross-validation and bootstrap optimism correction. Results In the matched descriptive comparison, pH and lactate remained robustly different after FDR correction, while highest intraoperative PASP, pulmonary valve VMAX, aortic valve VMAX, and heart rate were interpreted as exploratory signals. To reduce temporal bias, we separated a preoperative/peri-induction model from a secondary intraoperative monitoring model. In internal validation, the preoperative/peri-induction model achieved a repeated fivefold cross-validation AUC of 0.803 and a bootstrap optimism-corrected AUC of 0.813, with a Brier score of 0.151. The intraoperative monitoring model, which included highest intraoperative PASP, achieved a repeated fivefold cross-validation AUC of 0.853 and a bootstrap optimism-corrected AUC of 0.865, with a Brier score of 0.121. Conclusions Lower preoperative arterial pH, higher lactate, and dynamic intraoperative pulmonary pressure changes were associated with clinically documented circulatory decompensation in this exploratory single-center cohort. These internally assessed findings require external validation before clinical implementation.