M. E. Pulcrano1, H. J. Braun1, D. J. Weber1, B. Padilla1, N. L. Ascher1 1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA
Introduction: Extracorporeal membrane oxygenation (ECMO) is a method to artificially support respiratory and/or cardiac function when conventional techniques fail. Liver transplant recipients constitute a special patient group at high risk for developing pathologies such as acute respiratory distress syndrome and pneumonia in the settings of resuscitation and immunosuppression, respectively. Additionally, conditions such as portopulmonary hypertension and hepatopulmonary syndrome are directly related to cirrhosis and can contribute to respiratory distress both before and after transplantation. Over the past two decades, ECMO has been described as a treatment modality for acute pulmonary and/or cardiac disease following orthotopic liver transplantation (OLT) in the adult and pediatric populations. Here we present a series of OLT adult recipients placed on ECMO after transplantation for both respiratory and cardiac indications, which constitutes the largest described review in the United States.
Methods: The Extracorporeal Life Support Organization database of all patients at our academic institution who had undergone ECMO cannulation was cross-referenced with the institution’s liver transplant patient database, between 2002 and 2018. The patient and disease characteristics were identified, and the types of cannulation and outcomes were described
Results: Eight patients were identified, five men and three women aged 28-68. One patient was cannulated intraoperatively and the initiation of ECMO otherwise ranged from 3 days to 6 months after transplant in the remainder of the cohort. The cannulation time ranged from 1 day to 1.5 months. Four patients were placed on venovenous ECMO, for which the indications were hypoxemic respiratory failure (n=3) and inferior vena cava (IVC) obstruction (n=1). Four patients were placed on venoarterial ECMO for right heart failure and massive pulmonary embolism (PE). Three of eight patients survived to discharge and remain alive today. Of the deceased patients (n=5), three required ECMO as complications of pulmonary disease (portopulmonary hypertension (n=1) and hepatopulmonary syndrome (n=2)), one for technical complication of IVC obstruction, and one for a massive PE. Of the three patients who survived to discharge, one was cannulated intraoperatively for a massive PE, one was cannulated for hypoxemic respiratory failure in the setting of massive resuscitation for bleeding and coagulopathy, and one was cannulated for right heart failure. These patients remain alive from 5-13 months after transplantation.
Conclusion: ECMO is a useful modality to consider in liver transplant patients with severe cardiopulmonary failure. This adjunctive support is particularly effective if the etiology of cardiopulmonary failure is recognized promptly and is thought to be transient. This is the largest series in the United States and demonstrates a 38% survival rate, which is comparable to other reports in the literature from Asia.