S . Pervaiz Butt et al .: J Extra Corpor Technol 2024 , 56 , 191 – 202 193
Figure 1 . Depicts the milestones of ECMO , adapted and modified [ 4 ].
of ECMO to treat respiratory failure in a newborn took place in 1975 . Since then , advances in technology and techniques , along with the establishment of specialized ECMO centres globally , have significantly enhanced the safety and applicability of ECMO . As a result , it has become a valuable option for patients experiencing respiratory distress , offering them renewed hope and improved outcomes [ 4 , 5 ].
LTx , on the other hand , had its early roots in experimental attempts in the early 20th century , but significant progress was not achieved until the 1980 s . Fritz Derom performed the first successful single-lung transplant in 1981 where the patient survived for 10.5 months [ 6 ], Bruce Reitz followed with a successful double-lung transplant in 1986 . These pioneering procedures paved the way for further advancements in LTx . One of the critical breakthroughs was the development of improved immunosuppressive medications to prevent graft rejection . The introduction of calcineurin inhibitors like cyclosporine and tacrolimus significantly improved long-term survival rates . Better surgical techniques complemented by improved organ preservation methods , donor-recipient matching , and postoperative care have not only contributed to improved outcomes but also resulted in the expansion of the eligibility criteria for LTx . Today , LTx is an established treatment option for endstage lung diseases , and ongoing research aims to refine the procedure and further enhance outcomes [ 7 ].
With the expansion of potential eligible recipients , the use of ECMO during the perioperative period was realized . The first case successfully bridged to LTx with ECMO was reported in 1977 . The patient , who suffered from post-trauma respiratory failure , underwent bilateral LTx but survived only 10 days . In 1982 , another patient was successfully bridged to a single LTx after 19 days on ECMO , with a short-term positive outcome in terms of survival . These early cases highlighted the potential of ECMO as a temporary respiratory support strategy for patients awaiting LTx [ 8 ]. Today , the use of ECMO in the care of LTx patients is not uncommon and its use is likely to grow further in coming years . Figure 1 shows a timeline of some key ECMO milestones [ 4 ].
ECMO support in lung transplantation Lung preservation strategies
The field of LTx has witnessed significant advancements in preservation techniques over the past four decades . Initially , simple hypothermic immersion and topical cooling were used for lung preservation . However , the introduction of pulmonary artery flush combined with topical cooling became the standard technique due to its simplicity and effectiveness . Furthermore , the choice of preservation solution has evolved , with extracellular type solutions like Low-potassium dextran glucose ( LPDG ) and Celsior showing superior outcomes compared to intracellular type solutions .
Ex-vivo lung perfusion ( EVLP ) has gained popularity for assessing and preserving donor lungs , especially in cases of borderline lung suitability . Studies have indicated that storing lungs at 10 ° C during cold static preservation may maintain mitochondrial health and preserve organ function compared to the conventional 4 ° C storage temperature . Additionally , in-situ recruitment and assessment of atelectatic donor lungs prior to preservation have been found to improve post-transplant outcomes [ 9 ].
The study by Ali et al . explored a novel lung preservation technique involving alternating cycles of normothermic EVLP with cold static preservation at 10 ° C . This approach successfully preserved donor lungs for a total of 3 days , maintaining stable lung function and histological structures . This new technique holds promise for multi-day lung preservation and may have significant implications for organ transplantation [ 10 ].
Ali et al . also conducted a clinical trial investigating the safety and potential benefits of extending cold static preservation times at 10 ° C for LTx . The results indicated that longer preservation times were associated with a lower occurrence of grade 3 primary graft dysfunction at 72 h , suggesting that this strategy could enhance transplantation logistics and performance without adversely affecting outcomes [ 11 ].