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J Thorac Cardiovasc Surg 2002;124:626-627
© 2002 The American Association for Thoracic Surgery
Brief Communications |
From the Departments of Oncology and Thoracic Surgery,a Emergency Medicine,b Cardiovascular Surgery,c and Anesthesiology and Resuscitology,d Graduate School of Medicine and Dentistry, Okayama University, Okayama, Japan.
Received for publication March 25, 2002. Accepted for publication April 16, 2002. Address for reprints: Kazutoshi Kotani, Department of Oncology and Thoracic Surgery, Graduate School of Medicine and Dentistry, Okayama University, 2-5-1 Shikata, Okayama 700-8558, Japan (E-mail address: kk77{at}f7.dion.ne.jp).
Living-donor lung lobar transplantation has become an acceptable treatment for selected patients with end-stage pulmonary disease. A few cases of extracorporeal membrane oxygenation (ECMO) for acute severe respiratory failure after lung transplantation have been reported.
1-3 We present our experience with ECMO for acute respiratory failure resulting from pulmonary hemorrhage after living-donor lobar lung transplantation.
Clinical summary
On June 23, 2001, a 27-year-old woman with end-stage primary pulmonary hypertension underwent bilateral living-donor lobar transplantation with her father's right lower lobe and her brother's left lower lobe under cardiopulmonary bypass. Postoperative immunosuppression was a triple-drug therapy consisting of cyclosporine (INN ciclosporin), azathioprine, and prednisone. Two episodes of acute rejection required high-dose methylprednisolone intravenously. On postoperative day 15, severe hypoxia with a massive hemoptysis developed. The arterial oxygen saturation (Sao2) was 62% with 100% oxygen. Chest radiography revealed pulmonary hemorrhages in the right graft (Figure 1). Bronchoscopic examination demonstrated normal bronchial healing. She was placed on differential mechanical ventilation with a fraction of inspired oxygen of 1.0. Positive end-expiratory pressure of the right lung was 15 cm H2O, and that of the left lung was 5 cm H2O. At the same time, acute renal failure had developed. She was therefore treated with ECMO and continuous hemodiafiltration.
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Discussion
Primary graft failure is a significant complication after lung transplantation. ECMO can be used as a temporary support to allow the graft function to improve. Fortunately, ECMO after lung transplantation was only needed in 2.7% of the cases, as reported by Meyers and colleagues. 1 Zenati and associates 3 reported that 3.6% of patients required ECMO after lung transplantation. ECMO can be lifesaving, although mortality remains high. Zenati and associates 3 reported a mortality of 25%. Meyers and colleagues 1 reported a mortality of 42% for 12 patients in whom ECMO had been used for the same condition.
A pulmonary hemorrhage is a rare but serious complication after lung transplantation and is associated with serious morbidity. Pulmonary hemorrhage in lung transplant recipients may be caused by ischemic and infectious necrosis or by local hemodynamic factors. Local hemodynamic factors may be especially related to increased blood flow in the transplanted lung in a living-donor lung lobar transplantation, because the living-donor lung graft size is smaller than the bilateral transplant lung graft size. Therefore the living-donor lung graft vascular bed is smaller than the bilateral transplant lung graft vascular bed. In this case, graft function improved during ECMO.
ECMO is administered to patients with respiratory and circulatory failure in a state of shock accompanied by risk of bleeding. Thus the use of heparin is restrained. We used nafamostat mesilate as an anticoagulant during ECMO, because the patient had acute respiratory failure caused by pulmonary hemorrhage, accompanied by high risk of bleeding. Nafamostat mesilate is a synthetic protease inhibitor that has been found to inhibit various kinds of enzyme activities for coagulation. There are a few reports of ECMO with nafamostat mesilate as an anticoagulant. 4,5 Nagaya and coworkers 4 reported that bleeding was well controlled by nafamostat mesilate administration in 8 of 12 patients who had some hemorrhagic complications before or during ECMO. Daimon and associates 5 reported ECMO in a patient with acute respiratory failure caused by pulmonary hemorrhage in a Goodpasture-like syndrome.
ECMO was successfully used to treat a patient with acute respiratory failure from pulmonary hemorrhage after living-donor lobar lung transplantation with nafamostat mesilate as an anticoagulant. Nafamostat mesilate may be the first choice as an anticoagulant during ECMO for patients with a high risk of bleeding.
References
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