Center Volume and Extracorporeal Membrane Oxygenation Support at Lung Transplantation in the Lung Allocation Score Era

Abstract

Rationale: Outcomes related to extracorporeal membrane oxygenation (ECMO) used to bridge patients to lung transplantation in the context of center differences in transplant expertise have not been investigated.

Objectives: To determine the effects of ECMO at time of transplant on survival in adult patients who underwent transplant surgery in historically low- and high-volume centers.

Methods: The United Network for Organ Sharing database was used to classify centers according to transplant volume between May 2005 and May 2010 as low-volume centers (bottom 50% of centers), medium-volume centers (next 25%), or high-volume centers (top 25%). Influences of ECMO on post-transplant survival were estimated among adults receiving lung transplants between June 2010 and June 2015 based on historic center volume in the preceding 5 years.

Measurements and main results: Sixty-five centers were classified according to lung transplant volume in 2005-2010, with 8,228 adults (279 on ECMO) who underwent transplants at these centers between June 2010 and June 2015 included in the survival analysis. In multivariable Cox analysis stratified by center, we found that, in historically low-volume centers, ECMO was associated with increased post-transplant mortality hazard (hazard ratio, 1.968; 95% confidence interval, 1.083-3.577; P = 0.026). In contrast, in historically high-volume centers, ECMO had no adverse influence on post-transplant survival (hazard ratio, 0.853; 95% confidence interval, 0.596-1.222; P = 0.386).

Conclusions: An adverse effect of ECMO at the time of lung transplant was evident in low-volume centers but absent in centers with experience of performing more than 170 lung transplants in the first 5 years of the lung allocation score era.

Keywords: center volume; extracorporeal membrane oxygenation; lung allocation score; lung transplant; survival.