VV ECMO or VA ECMO is provided for a small subset of patients with severe, chronic, irreversible lung disease who pass a multidisciplinary assessment and are agreed to be suitable for bridge to lung transplantation with extracorporeal support.
Note: Pre-operative ECMO to support patients with severe pulmonary hypertension in the peri-transplant period does not constitute bridge to lung transplantation.
Bridge to lung transplantation is not a routine pathway and is only considered in exceptional circumstances and currently represent only 2-3% of our transplant population. Individual patient assessment and suitability can only be determined at the transplant centre.
Patients in extremis and/or located external to the transplant centre do NOT qualify for the bridge to transplant process and should NOT be supported with ECMO.
Referrals can be made at all times to the Transplant service for timely patient assessment. In particular patients with primary pulmonary hypertension should be referred and discussed early and occasionally present without a prior diagnosis and would still be considered for this process given the generally favourable outcomes.
Determination of suitability at the Alfred requires a detailed individual patient assessment, that is guided by the clinicians’ expertise and institutional experience. Broad categories of assessment are listed below, however, the minimal process prior to the application of ECMO involves the following process.
Patient with severe, irreversible lung disease judged suitable for ECMO bridge to transplant
Lung Transplant Unit approval for transplant
Lung Transplant Surgery Consultant approval for transplant
ICU team support ECMO as bridge to transplant
Patient/family informed about process
Broad categories of considerations for an ECMO bridge to the transplant process
- Patient age and constitutional reserve
- Current certainty about the pathology and suitability for this pathway
- Balance of lung allocation probability and risks of prolonged admission and ECMO run
- Minimal or supported other organ impairment that would not distract from the transplant aim
- Control of sepsis, treated infection that would not impede patient progress
- Patient agreeable to process that involves weeks of intensive care
- Patient/family acceptance of need to palliate from ECMO in the event of clinical deterioration