View Abstract

A5636 - Lung Retransplantation After Prolonged Veno-Venous Extracorporeal Membrane Oxygenation in a Child with Chronic Lung Allograft Dysfunction
Author Block: A. Herrera Camino1, S. C. Sweet2, N. O'Connor3, M. Shepard3, R. Pendino4, A. Gazit5, P. Eghtesady6, J. C. Lin5; 1Pediatric Critical Care/Pulmonary Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, United States, 2Pediatric Pulmonary Medicine, Washington University in St. Louis, Saint Louis, MO, United States, 3Perfusion Services, St. Louis Children's Hospital, St. Louis, MO, United States, 4Therapy Services, St. Louis Children's Hospital, St. Louis, MO, United States, 5Pediatric Critical Care Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, United States, 6Cardiothoracic Surgery, Washington University in St. Louis, Saint Louis, MO, United States.
Since introduction in 1972, Extracorporeal Membrane Oxygenation (ECMO) has become an accepted strategy for refractory cardiorespiratory failure. ECMO was soon deployed in 1975 as a bridge therapy to lung transplantation with increasing use, albeit with high mortality and morbidity. Advances in ECMO technology and improved patient selection criteria have led to improved outcomes after transplantation. Ambulatory ECMO is now utilized to minimize pre-transplant deconditioning and improve post-transplant outcomes but has many significant challenges. Successful implementation requires effective interprofessional team collaboration and has been associated with improved survival rates.
We describe successful use of ambulatory ECMO as a bridge to lung re-transplantation in a 6-year old female child with ABCA3 Surfactant Deficiency. She underwent initial Bilateral Lung Transplant (BLT) at age 2 years. At 3.5 years post-transplant, she developed Chronic Lung Allograft Dysfunction (CLAD) and refractory hypoxemic respiratory failure requiring invasive mechanical ventilation. VV-ECMO was initiated for rescue and maintained as a bridge while evaluating for re-transplantation candidacy.
Her ECMO course was complicated by intracranial hemorrhage, seizures, and opioid tolerance/dependence. She continued to require invasive mechanical ventilation, VV-ECMO support, and high dose analgosedation infusions for symptom relief. Nevertheless, through extensive interprofessional collaboration and care coordination, the medical team promoted wakefulness and near normal diurnal variation. This allowed both neurologic monitoring and progressive physical rehabilitation. Strategies to achieve this success include daily interprofessional rounds, setting weekly goals to optimize rehabilitation, adhering to sedation weaning protocols, and active family engagement in care. She thus maintained transplant eligibility and underwent lung re-transplantation on ECMO day 92.
Post-transplantation, she developed Primary Graft Dysfunction that necessitated tracheostomy tube placement for long term mechanical ventilation. She transitioned to low-level home ventilator support and was discharged home 3 months after transplant. At discharge, she was at baseline neurological function and ambulating with a walker. Unfortunately, she redeveloped progressive respiratory insufficiency and graft loss and died 6 months after re-transplantation.
This case highlights the feasibility of ECMO as a bridge to lung re-transplantation when approached with a comprehensive interprofessional team approach. Standardized guidelines for Intensive Care Unit (ICU) care in patients requiring mechanical support as a bridge to transplantation can mitigate the impact of adverse events, maintain patient conditioning, and improve transplant outcomes. Effective implementation of such guidelines requires close interprofessional team collaboration.