Impact of VV ECMO Use as Bridge to Lung Transplant in Patients with COVID-19 Associated Acute Respiratory Distress Syndrome

Lung transplantation is a potentially lifesaving treatment for critically ill patients with COVID-19-associated acute respiratory distress syndrome (ARDS). Many patients require extracorporeal membrane oxygenation (ECMO) as life-saving support when other traditional treatments fail. However, there is limited information regarding the long-term outcomes of VV-ECMO use as a bridge to lung transplantation in patients with ARDS. This was a retrospective review of an institutional lung transplant database. We included consecutive lung transplant recipients between June 2020 and June 2022. Demographic, clinical, laboratory, treatment data, the outcomes of lung transplantation, and survival were collected and analyzed. Kaplan-Meier and Wilcoxon tests were used to evaluate survival rates. Among the 41 lung transplant recipients for COVID-19-associated ARDS, 25 patients (median age 53 years [IQR, 36-55];11 women [44.0%]) had ECMO bridges and 16 patients (median age 54.5 years [IQR, 52.75 to 63];7 women [43.8%]) did not. For lung transplant recipients with ECMO bridges compared to those without, the median lung allocation scores were 88.1 vs. 74.9 (p<0.001). During transplantation, patients with COVID-19-associated ARDS received transfusions with a median of ten units of packed red blood cells vs. two units in those without ECMO bridges;96.0% vs. 93.8% underwent intraoperative venoarterial ECMO, and the median operative time was 9.5 hrs. vs. 7.8 hrs., respectively. Postoperatively, the rates of primary graft dysfunction grade 3, within 72 hrs., were 44% in the ECMO bridge vs. 0% in those without them. The median duration of intensive care unit stays was 20 days vs. 13 days, and the median post-lung transplant hospitalization duration was 35 days vs. 19.5 days, respectively. After follow-up (median follow-up period: 448 days [IQR, 314-664] in patients with ECMO bridges vs. 417 days [IQR, 389.5-506] in patients without them), one-year survival rates were 78.3% in patients with ECMO bridges and 100.0% in patients without (p=0.06). In this single-center case series of 41 consecutive patients who underwent lung transplantation for COVID-19-associated ARDS, patients on an ECMO bridge showed a more severe cohort. However, there was no significant difference in the overall outcomes between the two groups (p=0.06). [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Right Heart Recovery after Lung Transplantation in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome: A Cohort Study

In patients with COVID-19-associated acute respiratory distress syndrome (ARDS), decreased pulmonary compliance, increased pulmonary vascular resistance and micro pulmonary thrombosis increase the right heart burden, which can lead to right heart failure. However, the impact of lung transplantation for ARDS on the right heart is unclear. Therefore, we evaluated changes in heart function and structural abnormalities with pre- and postoperative transthoracic echocardiography (TTE). This study was a retrospective review of the institutional lung transplantation database from June 2020 to June 2022. Pre- and postoperative TTE were performed, and postoperative TTE beyond 90 days was recorded. Right ventricular (RV) function and size were evaluated and scored. The Wilcoxon signed-rank test was used to compare pre- and postoperative TTE values. During the period, 42 patients underwent lung transplantation for COVID-19-associated ARDS: 10 were excluded (two single-lung, one lobar, one dual-organ transplant, and six patients with missing postoperative TTE data);and 32 were included in the study. TTE was evaluated at a median of 15 days preoperatively (IQR 9.5-30) and 144.5 days postoperatively (IQR 112-210). Pre- and postoperative TTE showed significant changes in mitral A, lateral E', RV estimated systolic pressure (RVSP), RV function and size (Figure 1 and Table 1). In patients with severe right heart dysfunction due to COVID-19-associated ARDS, RV function and structure normalized within a relatively short period after lung transplantation. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Feasibility of Veno-Venous Extracorporeal Membrane Oxygenation Using ProtekDuoTM Cannula Ina Patients with COVID-19-Associated Acute Respiratory Distress Syndrome with Severe Right Heart Dysfunction Before Lung Transplantation

Severe right heart failure (RHF) is a known complication of pulmonary hypertension, which increases mortality before lung transplantation. The safety and feasibility of venovenous (VV)-extracorporeal oxygenation (ECMO) using ProtekDuoTM (CardiacAssist Inc., Pittsburgh, PA) as a bridge to lung transplantation in severe RHF caused have not been well studied. This study aimed to evaluate the safety and feasibility of VV-ECMO using ProtekDuoTM as a bridge to lung transplantation in patients with severe RHF. This study was a prospective review of the institutional lung transplantation database from June 2020 to June 2022. Patients who underwent lung transplantation with VV-ECMO using ProtekDuoTM for COVID-19 associated acute respiratory distress syndrome (ARDS) were prospectively enrolled;and preoperative and postoperative transthoracic echocardiographic (TTE) data were analyzed. RV function and size were evaluated and scored. The Wilcoxon signed-rank test was used to compare pre- and post-operative TTE values. During the study period, 20 patients underwent lung transplantation for COVID-19-associated ARDS with preoperative VV-ECMO using ProtekDuoTM. TTE was assessed at a median of 15 days preoperatively (IQR, 7.75-31) and 155.5 days postoperatively (IQR, 112-210). Pre and post-operative median RVSP was 45.4 mm Hg (IQR, 29.4-49.0) and 30.0 mm Hg (IQR, 28.0-35.0), p=0.02, and the median mitral valve A was 0.70 cm/s (IQR, 0.70-0.80) and 0.55 cm/s (IQR, 0.50-0.70), p=0.03 (Table1). All patients were hemodynamically stable with active rehabilitation and did not require inotropes or inhaled nitric oxide. VV-ECMO with ProtekDuoTM for patients with COVID-19-associated ARDS before lung transplantation can stabilize patients without significant complications and allows active rehabilitation of patients with severe RHF. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Cytomegalovirus Serologic Mismatch Impact Long-Term Outcomes after Lung Transplantation

Cytomegalovirus (CMV) infection is associated with poor outcomes after solid organ transplantation. The long-term impact of donor and recipient CMV serological status on lung transplant outcomes has been considered a risk factor for mortality, which donor CMV-IgG positive-recipient CMV-IgG negative (D+R-) group is a high risk for CMV infection and mortality. However, the risk factors in this group of patients remain unclear. We evaluated the impact of donor and recipient CMV status on long-term outcomes, as well as the risk factors for CMV infection. This was a prospective review of the institutional lung transplantation database from June 2014 to June 2022. Data on patient characteristics, pre-transplantation laboratory values, postoperative outcomes, and CMV infection were collected. All patients received a prophylactic dose of valganciclovir hydrochloride (900 mg once daily) after lung transplantation. The donor positive-recipient CMV-IgG negative group was defined as the CMV-mismatch group. The results were analyzed using the chi-square test, Mann-Whitney U test, t-test, logistic regression analyses, and receiver operating characteristic curve analysis. During the study period, 257 patients underwent lung transplantation. CMV infection was detected in 69 patients (26.8%):25 of 203 (12.3%) in the non-CMV mismatch group and 29 of 54 (53.7%) in the CMV mismatch group (p<0.001). CMV infection occurred 395 days (IQR;264-452) in the entire cohort. In multivariate logistic analysis, COVID-19-associated acute respiratory distress syndrome etiology, lower albumin level, and CMV mismatch were independent factors for CMV infection (COVID-19-related ARDS, OR=3.03, 95% CI=1.20-7.64, p=0.02;albumin [g/dl], OR=0.34, 95% CI=0.16-0.70, p<0.01;CMV mismatch, OR=6.66, 95% CI=2.79-15.9, p<0.001). Receiver operating characteristic curve analysis showed that an albumin of 4.0 g/dl was the cut-off value (area under the curve=0.64) for the risk of CMV infection. In the CMV mismatch group, hemodialysis use after discharge was associated with CMV infection (OR=9.10, 95% CI=1.02-82.4, p=0.04). In patients with CMV mismatch, hemodialysis use was an independent predictor of CMV infection. Further studies are needed to determine the risks and benefits of extending CMV prophylaxis or aggressive CMV treatment, particularly in high-risk groups. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

A Case of Successful Lung Transplantation Following 10 Months of Mechanical Ventilator Dependence

Historically, patients requiring mechanical ventilation support were precluded from lung transplant listing, attributable to increased short and long-term mortality. We present a case of successful bilateral lung transplant for a patient supported with mechanical ventilation for 10 months following an episode of COVID associated ARDS with resultant fibrosis. Our patient is a 65-year-old man with chronic respiratory failure secondary to COVID-19 associated ARDS and pulmonary fibrosis. He initially presented with acute hypoxic respiratory failure requiring intubation and later cannulation for VV-ECMO, which lasted 136 days. Due to severe critical illness myopathy, he remained ventilator dependent via tracheostomy and required a gastrostomy tube for nutrition. His course was further complicated by recurrent ventilator associated pneumonia (VAP) due to Pseudomonas Aeruginosa (PsA) and Stenotrophomonas Maltophilia as well as acute venous thromboembolism. Subsequently, the patient was transferred to our hospital for a lung transplant evaluation following persistent ventilator dependence for a total of nine months since his initial hospitalization. The primary barrier towards transplant listing was the patient's severe deconditioning and myopathy. Our patient underwent aggressive physical therapy, and by the time of listing, he was able to bear weight and walk three feet with physical therapy. The patient underwent bilateral lung transplant six days after listing. His course was complicated by ventilator associated pneumonia due to multi-drug resistant PsA. He required prolonged mechanical ventilator support post-operatively, but his tracheostomy was successfully decannulated on POD 38. He was discharged to an inpatient rehabilitation facility on post-op day 42 and discharged home around POD 70. He continues to follow-up and reports doing well with stable spirometry with no evidence of allograft rejection. This report describes the successful transplantation of a ventilator dependent patient for 10 months with associated severe myopathy. Despite our patient's high-risk status and severe myopathy, he demonstrated good rehabilitation potential with resulting good outcome post-transplantation. He is currently 19 months post-transplant, and his course has been uncomplicated since discharge. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

A Multicenter Prospective Registry Study of Lung Transplant Recipients Hospitalized with COVID-19

Purpose Outcomes of lung transplant recipients (LTR) hospitalized for COVID-19 and comparisons to non-lung solid organ transplant recipients (SOTR) are incompletely described. Methods Using a multicenter prospective registry of SOTR, we examined 28-day outcomes (mortality [primary outcome], intensive care unit (ICU) admission, mechanical ventilation, and bacterial pneumonia) among both LTR and non-lung SOTR hospitalized with laboratory-confirmed COVID-19 diagnosed between March 1, 2020 and September 21, 2020. Data were analyzed using Stata (StataCorp, College Station, TX);chi-square tests were used to compare categorical variables and multivariable logistic regression was used to assess risk factors for mortality. Results The cohort included 72 LTR and 392 non-lung SOTR (Table 1). Overall, 28-day mortality trended higher in LTR vs. non-lung SOTR (27.8% vs. 19.9%, P=0.136). Other 28-day outcomes were similar between LTR and non-lung SOTR: ICU admission (45.8% vs. 39.1%, P=0.28), mechanical ventilation (32.9% vs. 31.1%, P=0.78), and bacterial pneumonia (15.3% vs. 8.2%, P=0.063). Congestive heart failure, diabetes, age >65 years, and obesity (BMI >= 30) were independently associated with mortality in non-lung SOTR, but not in LTR (Table 2). Conclusion In this large prospective cohort comparing lung and non-lung SOTR hospitalized for COVID-19, there were high but not significantly different rates of short-term morbidity and mortality. Baseline comorbidities appeared to drive mortality in non-lung SOTR but not LTR. Further studies are needed to identify risk factors for mortality among LTR.