# Elective Use of Intraoperative Extracorporeal Membrane Oxygenation in Patients With Pulmonary Fibrosis Reduces Primary Graft Dysfunction After Bilateral Lung Transplantation

## TL;DR

Using ECMO during lung transplants for patients with pulmonary fibrosis reduces complications and improves survival.

## Contribution

A more liberal elective use of intraoperative ECMO in PF patients during LTx reduces primary graft dysfunction and improves outcomes.

## Key findings

- Elective ECMO use after 2020 significantly reduced primary graft dysfunction grade 3 in PF patients.
- One-year graft survival showed a trend toward improvement with elective ECMO use.
- Elective ECMO was increasingly used in patients with higher pulmonary arterial pressure and resistance.

## Abstract

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).

Patients with PF undergoing LTx between January 2012 and January 2025 were included and sub-divided into the period before and after the implementation of a more liberal intraoperative use of ECMO support in January 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.

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 h post-transplant between elective (17% vs 3%, P = .002), non-elective (38% vs 0%, P = .016), and no ECMO (12% vs 3%, P = .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.

The use of a more liberal, elective intraoperative ECMO support in patients with PF led to an improvement of PGD prevalence and survival early after lung transplantation.

Lung transplantation (LTx) is an established treatment for patients with end-stage pulmonary fibrosis (PF).