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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The use of extracorporeal membrane oxygenation &#40;ECMO&#41; has grown exponentially in the last 20 years&#44; mainly due to technological advances in systems&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> and the favorable results of the technique in adult respiratory distress syndrome during the influenza A &#40;H1N1&#41; epidemic&#44; when several groups achieved survival greater than 70&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;3</span></a> especially in patients transferred to ECMO reference centers&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">ECMO is a rescue therapy that replaces cardiac and respiratory function &#40;venoarterial ECMO&#41; or respiratory function &#40;venovenous ECMO&#41; in patients with severe heart and&#47;or respiratory disease&#44; when the risk of mortality is high in spite of optimal standard treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> This technique is useful in 3 situations in lung transplantation &#40;LT&#41;&#58; as a bridge to LT with or without mechanical ventilation &#40;MV&#41;&#44; intraoperative cardiac and&#47;or respiratory support during cardiopulmonary bypass replacement&#44; and primary and postoperative graft dysfunction&#46; ECMO as a bridge to LT is the most common indication due to the scarcity of lung donors and high waiting list mortality rates in countries such as the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> According to the international Extracorporeal Life Support Organization registry&#44; 1066 ECMO systems were used in LT patients between 1990 and 2016&#44; with 65&#37; survival at hospital discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Until 2010&#44; the use of MV and ECMO in the pre-transplantation period was a contraindication for LT&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Nowadays&#44; when MV is insufficient&#44; ECMO can be used as a bridge to LT in highly selected patients in experienced centers&#44; in cases in whom the indication for LT has already been established&#44; and in very exceptional cases in whom LT can be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> In the latter situation&#44; ECMO can allow time for a decision to be made or for completion of procedures for inclusion in the LT waiting list&#46; It has not yet been established if the best alternative for these patients is the exclusive use of MV or combined MV and ECMO&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> but we do know that the use of pre-transplantation MV is associated with higher mortality in the post-transplantation period&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> due to immobilization resulting from sedation and complications associated with MV&#44; pneumonia in particular&#46; More recently&#44; evidence has shown that the use of pre-transplantation MV is associated with a 2-fold increase in the risk of death in the first 6 months post-transplantation&#44; compared with patients who did not receive MV&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> In a study of 60 patients&#44; Fuehner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> found that survival at 6 months was higher in the group who received ECMO without MV&#44; compared to the group who received MV &#40;80&#37; vs 50&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46; Avoiding MV and using ECMO in awake patients leads to better rehabilitation and obviates MV-related complications&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">ECMO offers clear benefits to patients with terminal respiratory failure and&#47;or severe pulmonary hypertension with right ventricular failure who cannot maintain the optimal physical situation necessary to tolerate a LT&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> It also indirectly increases the patient&#39;s likelihood of LT by increasing their lung allocation score &#40;LAS&#41;&#44; because although ECMO is not specifically scored&#44; elevated FiO<span class="elsevierStyleInf">2</span> and the need for MV are&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> A meta-analysis of 14 retrospective studies and 441 patients in total showed that ECMO as a bridging strategy was successful in 50&#37; and 83&#37; of cases&#44; with a 1-year survival of 50&#37;&#8211;90&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> mortality being attributed to multiorgan failure&#44; septic shock&#44; heart failure&#44; and hemorrhagic complications derived from anticoagulation from the ECMO system&#46; Consequently&#44; we must always weigh up the possible complications associated with these devices &#40;which become more frequent over time&#41; against their benefits&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> taking into account that the longer duration and improved biocompatibility of the membranes&#44; the possibility of reducing or withdrawing anticoagulation from the systems&#44; and the availability of multiple configurations and systems have been key factors in the growing use of ECMO and improved survival in LT&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The factors influencing prognosis in patients receiving ECMO as a bridge to LT are not fully established&#44; but as they become clear they will help improve patient selection and outcomes&#46; The success of ECMO depends on knowing which patients should receive it and when&#44; even though this selection is not without controversy&#46; We must select young patients with no organ compromise other than heart and lung failure&#44; who have good prospects for rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Unfortunately&#44; the only studies available to date are a few case series with a wide range of indications for LT&#44; types of ECMO support used&#44; clinical situations&#44; LAS scores&#44; and bridge duration&#44; and no maximum waiting time or age limits for starting ECMO&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7&#44;8</span></a> In a recently published survey conducted in the United States&#44; 55&#37; of centers reported no limits with regard to maximum pre-LT ECMO support&#44; and 30&#37; imposed a maximum of 10 days&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> However&#44; the duration of pre-LT ECMO does appear to affect patient prognosis&#44; and risk of mortality increases when it is administered for more than 14 days&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> In the same survey&#44; an age greater than 65 years was considered a contraindication in 45&#37; of centers&#44; while 36&#37; had no specific age cut-off&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There is no doubt that level of clinician expertise and underlying diseases directly affect the prognosis of pre-LT ECMO support&#44; both in terms of the effectiveness of the strategy and 1-year survival&#46; Centers with a high volume of LT that use ECMO have higher 1- and 2-year survival rates than low-volume centers&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">If we analyze the most frequent indications of lung transplantation&#44; we see that in a recent study&#44; 1-year survival in cystic fibrosis was greater than in interstitial disease &#40;70&#46;3&#37; vs 46&#46;7&#37;&#41;&#44; with a median overall survival of 80&#46;3&#37; at 1 year and 84&#37; at 2 years&#46; In that study&#44; only 15&#37; of patients were receiving MV at the start of ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">One-year survival&#44; then&#44; is similar in patients receiving ECMO with respect to those who have not received it in centers with a high volume of LT and use of ECMO&#44; where the absence of MV and sedation&#44; the use of respiratory physiotherapy&#44; and active mobilization play a key role in the correct selection of candidates&#46; It is clear that MV can only be avoided in highly selected cases&#44; such as cystic fibrosis patients&#44; and patients with terminal interstitial disease and hypoxemic respiratory failure are not candidates for this technique&#46; In the meantime&#44; ECMO is a valid alternative bridging strategy to LT with or without MV in highly selected patients whenever it is used in reference centers with experience in the use of this technique&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Technological advances are helping to simplify extracorporeal respiratory support systems for the elimination of CO<span class="elsevierStyleInf">2</span> through a single venous access and lower blood flows than required in an ECMO system&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> These CO<span class="elsevierStyleInf">2</span>-eliminating systems can be used in hypercapnic patients without MV or in combination with non-invasive VM on the bridge to LT&#44; allowing patients to remain mobile and receive physiotherapy&#46;</p></span>"
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Editorial
Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation
Membrana de oxigenación extracorpórea en el puente al trasplante de pulmón
Marta López Sánchez
Corresponding author
martalopez@humv.es

Corresponding author.
, María Isabel Rubio López
Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The use of extracorporeal membrane oxygenation &#40;ECMO&#41; has grown exponentially in the last 20 years&#44; mainly due to technological advances in systems&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> and the favorable results of the technique in adult respiratory distress syndrome during the influenza A &#40;H1N1&#41; epidemic&#44; when several groups achieved survival greater than 70&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;3</span></a> especially in patients transferred to ECMO reference centers&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">ECMO is a rescue therapy that replaces cardiac and respiratory function &#40;venoarterial ECMO&#41; or respiratory function &#40;venovenous ECMO&#41; in patients with severe heart and&#47;or respiratory disease&#44; when the risk of mortality is high in spite of optimal standard treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> This technique is useful in 3 situations in lung transplantation &#40;LT&#41;&#58; as a bridge to LT with or without mechanical ventilation &#40;MV&#41;&#44; intraoperative cardiac and&#47;or respiratory support during cardiopulmonary bypass replacement&#44; and primary and postoperative graft dysfunction&#46; ECMO as a bridge to LT is the most common indication due to the scarcity of lung donors and high waiting list mortality rates in countries such as the United States&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> According to the international Extracorporeal Life Support Organization registry&#44; 1066 ECMO systems were used in LT patients between 1990 and 2016&#44; with 65&#37; survival at hospital discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Until 2010&#44; the use of MV and ECMO in the pre-transplantation period was a contraindication for LT&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Nowadays&#44; when MV is insufficient&#44; ECMO can be used as a bridge to LT in highly selected patients in experienced centers&#44; in cases in whom the indication for LT has already been established&#44; and in very exceptional cases in whom LT can be considered&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> In the latter situation&#44; ECMO can allow time for a decision to be made or for completion of procedures for inclusion in the LT waiting list&#46; It has not yet been established if the best alternative for these patients is the exclusive use of MV or combined MV and ECMO&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> but we do know that the use of pre-transplantation MV is associated with higher mortality in the post-transplantation period&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> due to immobilization resulting from sedation and complications associated with MV&#44; pneumonia in particular&#46; More recently&#44; evidence has shown that the use of pre-transplantation MV is associated with a 2-fold increase in the risk of death in the first 6 months post-transplantation&#44; compared with patients who did not receive MV&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> In a study of 60 patients&#44; Fuehner et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> found that survival at 6 months was higher in the group who received ECMO without MV&#44; compared to the group who received MV &#40;80&#37; vs 50&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;02&#41;&#46; Avoiding MV and using ECMO in awake patients leads to better rehabilitation and obviates MV-related complications&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">ECMO offers clear benefits to patients with terminal respiratory failure and&#47;or severe pulmonary hypertension with right ventricular failure who cannot maintain the optimal physical situation necessary to tolerate a LT&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> It also indirectly increases the patient&#39;s likelihood of LT by increasing their lung allocation score &#40;LAS&#41;&#44; because although ECMO is not specifically scored&#44; elevated FiO<span class="elsevierStyleInf">2</span> and the need for MV are&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> A meta-analysis of 14 retrospective studies and 441 patients in total showed that ECMO as a bridging strategy was successful in 50&#37; and 83&#37; of cases&#44; with a 1-year survival of 50&#37;&#8211;90&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> mortality being attributed to multiorgan failure&#44; septic shock&#44; heart failure&#44; and hemorrhagic complications derived from anticoagulation from the ECMO system&#46; Consequently&#44; we must always weigh up the possible complications associated with these devices &#40;which become more frequent over time&#41; against their benefits&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> taking into account that the longer duration and improved biocompatibility of the membranes&#44; the possibility of reducing or withdrawing anticoagulation from the systems&#44; and the availability of multiple configurations and systems have been key factors in the growing use of ECMO and improved survival in LT&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The factors influencing prognosis in patients receiving ECMO as a bridge to LT are not fully established&#44; but as they become clear they will help improve patient selection and outcomes&#46; The success of ECMO depends on knowing which patients should receive it and when&#44; even though this selection is not without controversy&#46; We must select young patients with no organ compromise other than heart and lung failure&#44; who have good prospects for rehabilitation&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Unfortunately&#44; the only studies available to date are a few case series with a wide range of indications for LT&#44; types of ECMO support used&#44; clinical situations&#44; LAS scores&#44; and bridge duration&#44; and no maximum waiting time or age limits for starting ECMO&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">7&#44;8</span></a> In a recently published survey conducted in the United States&#44; 55&#37; of centers reported no limits with regard to maximum pre-LT ECMO support&#44; and 30&#37; imposed a maximum of 10 days&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> However&#44; the duration of pre-LT ECMO does appear to affect patient prognosis&#44; and risk of mortality increases when it is administered for more than 14 days&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> In the same survey&#44; an age greater than 65 years was considered a contraindication in 45&#37; of centers&#44; while 36&#37; had no specific age cut-off&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There is no doubt that level of clinician expertise and underlying diseases directly affect the prognosis of pre-LT ECMO support&#44; both in terms of the effectiveness of the strategy and 1-year survival&#46; Centers with a high volume of LT that use ECMO have higher 1- and 2-year survival rates than low-volume centers&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">If we analyze the most frequent indications of lung transplantation&#44; we see that in a recent study&#44; 1-year survival in cystic fibrosis was greater than in interstitial disease &#40;70&#46;3&#37; vs 46&#46;7&#37;&#41;&#44; with a median overall survival of 80&#46;3&#37; at 1 year and 84&#37; at 2 years&#46; In that study&#44; only 15&#37; of patients were receiving MV at the start of ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">One-year survival&#44; then&#44; is similar in patients receiving ECMO with respect to those who have not received it in centers with a high volume of LT and use of ECMO&#44; where the absence of MV and sedation&#44; the use of respiratory physiotherapy&#44; and active mobilization play a key role in the correct selection of candidates&#46; It is clear that MV can only be avoided in highly selected cases&#44; such as cystic fibrosis patients&#44; and patients with terminal interstitial disease and hypoxemic respiratory failure are not candidates for this technique&#46; In the meantime&#44; ECMO is a valid alternative bridging strategy to LT with or without MV in highly selected patients whenever it is used in reference centers with experience in the use of this technique&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Technological advances are helping to simplify extracorporeal respiratory support systems for the elimination of CO<span class="elsevierStyleInf">2</span> through a single venous access and lower blood flows than required in an ECMO system&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> These CO<span class="elsevierStyleInf">2</span>-eliminating systems can be used in hypercapnic patients without MV or in combination with non-invasive VM on the bridge to LT&#44; allowing patients to remain mobile and receive physiotherapy&#46;</p></span>"
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Article information
ISSN: 15792129
Original language: English
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2022 December 47 52 99
2022 November 48 29 77
2022 October 42 43 85
2022 September 20 15 35
2022 August 26 35 61
2022 July 26 38 64
2022 June 16 24 40
2022 May 28 31 59
2022 April 24 28 52
2022 March 24 37 61
2022 February 34 35 69
2022 January 22 33 55
2021 December 34 32 66
2021 November 31 43 74
2021 October 34 39 73
2021 September 33 50 83
2021 August 22 35 57
2021 July 18 24 42
2021 June 36 36 72
2021 May 35 43 78
2021 April 50 67 117
2021 March 45 33 78
2021 February 22 23 45
2021 January 19 11 30
2020 December 25 18 43
2020 June 1 2 3
2020 March 15 10 25
2020 February 17 14 31
2020 January 28 11 39
2019 December 31 9 40
2019 November 38 15 53
2019 October 22 5 27
2019 September 24 6 30
2019 August 16 13 29
2019 July 23 22 45
2019 June 34 10 44
2019 January 1 0 1
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