A25-16 Complex Bilateral Lung Transplantation After Prior Pleurodesis for Thoracic Endometriosis: Role of Proactive Early ECMO in OR

Abstract Background Bilateral lung transplantation in patients with prior pleurodesis for thoracic endometriosis is technically demanding due to dense pleural adhesions, which increase bleeding risk and operative time, particularly in explanting the native lungs (1). Prior pleurodesis is recognized as a high-risk feature (2). Thoracic endometriosis further complicates surgery through multifocal pleural involvement and fibrosis (3). In such recipients, intraoperative veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides cardiopulmonary support when single-lung ventilation is not tolerated (4). Intraoperative ECMO use has been associated with improved graft function and lower transfusion requirements compared with cardiopulmonary bypass (5). Case 48-year-old woman with cystic-bullous lung disease, recurrent catamenial pneumothoraces, thoracic endometriosis, and prior bilateral talc pleurodesis underwent bilateral lung transplantation via clamshell thoracotomy. Dense adhesions caused unavoidable lung injury, severe hemorrhage, and ventilatory failure, prompting initiation of VA-ECMO. Also, requiring massive transfusion and delayed chest closure for coagulopathy. She was transferred to ICU, where she remained in refractory respiratory failure, primary graft dysfunction (PGD) and right ventricular failure requiring conversion to V-AV ECMO. Other complications included hemolysis, ischemic hepatitis, and recurrent bleeding requiring re-exploration. Following resolution of cardiogenic shock, converted to VV-ECMO and underwent tracheostomy for prolonged ventilation. She also needed renal replacement therapy. By week 3, sedation was weaned, early mobilization initiated, and was decannulated from VV-ECMO (postoperative day 21). Discussion Intraoperative extracorporeal support contributes to improved outcomes in complex lung transplantation. Prior pleural interventions and dense adhesions substantially heighten operative complexity, often necessitating rapid transition to mechanical circulatory support for hemodynamic and ventilatory stabilization. Prophylactic or early VA-ECMO during high-risk transplantation improves primary graft function and reduces reperfusion injury compared with cardiopulmonary bypass, while maintaining lower transfusion and inflammatory burdens. Several preoperative variables—advanced recipient age, elevated pulmonary arterial pressure, prolonged mechanical ventilation, higher APACHE II score, and fibrotic or re-transplant are independent predictors of intraoperative ECMO requirement. The presence of multiple high-risk features in this patient justified proactive initiation of ECMO and adaptive circuit management to maintain physiologic stability. Together, these data reinforce the role of early, planned extracorporeal support and multidisciplinary management in ensuring procedural success among technically complex, post-pleurodesis lung transplant. Conclusion Bilateral lung transplantation after pleurodesis for thoracic endometriosis remains surgically complex. Proactive ECMO use, individualized support, and guideline-directed critical-care management are essential to recovery. This case highlights the need for ongoing refinement of intraoperative and postoperative strategies for high-risk lung transplant recipients. Figure: First OR and last available CXR) This abstract is funded by: None