Intraoperative extracorporeal support for lung transplant: a systematic review and network meta-analysis

Pettenuzzo, T., Ocagli, H., Sella, N. et al. Intraoperative extracorporeal support for lung transplant: a systematic review and network meta-analysis. J Anesth Analg Crit Care 4, 81 (2024). https://doi.org/10.1186/s44158-024-00214-x

Summary of Intraoperative Extracorporeal Support for Lung Transplant: A Systematic Review and Network Meta-analysis (Pettenuzzo et al.)

Abstract Summary: Pettenuzzo et al. conducted a systematic review and network meta-analysis evaluating the efficacy and safety of intraoperative extracorporeal supports—veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and cardiopulmonary bypass (CPB)—compared to off-pump strategies during lung transplantation (LT). Their analysis revealed that off-pump approaches generally offered better outcomes, while V-A ECMO, particularly as a default strategy, showed superior results compared to CPB in several clinical outcomes, except for red blood cell (RBC) transfusion needs.

Key Points:

1. Study Scope: The analysis included 27 observational studies comprising 6,113 lung transplant patients, comparing outcomes across intraoperative strategies including off-pump, default V-A ECMO (ECMOd), rescue V-A ECMO (ECMOr), and CPB.
2. Blood Product Consumption: All extracorporeal support strategies required more blood products compared to off-pump surgery, with ECMOd and ECMOr needing fewer fresh frozen plasma (FFP) and platelet transfusions than CPB, although CPB used fewer RBC units compared to ECMO.
3. Mechanical Ventilation and ICU Stay: ECMOd and CPB both resulted in significantly longer durations of invasive mechanical ventilation (IMV) and extended intensive care unit (ICU) lengths of stay compared to off-pump surgery.
4. Surgical Duration: The surgical procedure duration was marginally longer for ECMOd and CPB compared to the off-pump strategy, indicating slightly increased complexity with extracorporeal supports.
5. Postoperative ECMO Support: The need for postoperative ECMO support was lowest in off-pump procedures, with no significant difference observed among different extracorporeal strategies.
6. Mortality Rates: Off-pump surgery demonstrated significantly lower mortality rates compared to ECMOd, ECMOr, and CPB, highlighting the potential safety and efficacy of off-pump strategies.
7. Influence of Patient Characteristics: Older age, male gender, and higher body mass index (BMI ≥25 kg/m²) negatively impacted RBC transfusions, ICU length of stay, surgical duration, postoperative ECMO requirements, and overall mortality regardless of the intraoperative strategy used.
8. Quality of Evidence: Evidence quality was generally low due to methodological limitations, significant variability among studies, and potential biases, underscoring the need for caution in interpreting these findings.
9. Sensitivity Analysis: Subgroup analyses by publication year, geographical region, and risk of bias revealed consistent findings, although some variations in blood product requirements and postoperative outcomes were influenced by geographical and temporal factors.
10. Future Directions: The authors advocate for further prospective randomized studies to optimize intraoperative management strategies, reduce variability in clinical practice, and improve outcomes in lung transplantation.

Conclusion: This network meta-analysis demonstrates that off-pump strategies outperform extracorporeal supports in lung transplantation across most clinical outcomes, although ECMO, especially as a default approach, is preferable to CPB when extracorporeal support is necessary. Future studies should focus on refining patient selection and standardizing clinical protocols to enhance transplantation outcomes.

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Discussion Questions:

1. How can future clinical trials best address the methodological limitations highlighted by this review to clarify optimal intraoperative support strategies?
2. What patient-specific factors should guide the clinical decision-making process for selecting intraoperative support strategies during lung transplantation?
3. Could advancements in ECMO technology further improve its outcomes, potentially making it a more favorable routine option compared to off-pump strategies?

Javier Amador-Castañeda, BHS, RRT, FCCM, PNAP

Interprofessional Critical Care Network (ICCN)

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