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Should Lung Transplantation Be Performed for Patients on Mechanical Respiratory Support? The U.S. Experience
David P Mason, Lucy Thuita, Edward R Nowicki, Sudish C Murthy, Gosta B Pettersson, Eugene H Blackstone
Cleveland Clinic, Cleveland, OH
BACKGROUND: To 1) compare survival after lung transplantation (LTx) in patients requiring pre-transplant mechanical ventilation (MV) or extracorporeal membrane oxygenation (ECMO) with those not requiring mechanical support, and 2) identify risk factors for mortality.
METHODS: Data were obtained from the United Network for Organ Sharing for LTx from 10/1987 to 1/2008. 15,934 primary transplants were performed_586 in patients on MV and 51 on ECMO. Differences between nonsupport and those supported by MV or ECMO were expressed as two propensity scores for use in comparing risk-adjusted survival.
RESULTS: Unadjusted survival at 1, 6, 12, and 24 months was 83%, 67%, 62%, and 57% for MV; 72%, 53%, 50%, and 45% for ECMO; and 93%, 85%, 79%, and 70% for unsupported patients (P<.0001), respectively. MV recipients were younger, had lower FVC%, and diagnoses other than emphysema. ECMO recipients were also younger, had higher body mass index, and diagnoses other than cystic fibrosis/bronchiectasis. Once these variables, transplant year, and propensity for mechanical support were accounted for, survival remained worse after LTx for MV and ECMO patients.
CONCLUSIONS: Although survival after LTx is worse when preoperative mechanical support is necessary, it is not dismal. Thus, additional risk factors for mortality should be considered when selecting patients for LTx to maximize survival. Reduced survival for this high-risk population raises the important ethical issue of balancing maximal individual patient survival against benefit to the maximum number of patients. 
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