To discuss technical strategies and considerations to facilitate intraoperative extracorporeal membrane oxygenation (ECMO) management during lung transplantation.

We review our institutional approach to the management of intraoperative ECMO during bilateral lung transplantation. Our proposed algorithm summarizes technical considerations based on the mechanical circulatory support (MCS) platform encountered in the operating room.

For patients without preoperative ECMO, an assessment of indications and available configurations in anticipation of the need for intraoperative ECMO is required. Our initial MCS approach for isolated respiratory failure is venovenous (VV) ECMO. If patients have pulmonary hypertension or right ventricular dysfunction with acceptable vascular access, then peripheral venoarterial (VA) ECMO is attempted. However, we maintain a low threshold for conversion to central aortic cannulation with a modified Seldinger technique through a clamshell or bilateral anterior thoracotomy incision. For patients bridged to lung transplantation on VV ECMO or venopulmonary (VPa) ECMO, our initial approach is to reverse flow through existing venous cannulas when possible and provide outflow through central aortic cannulation. Finally, for patients bridged to lung transplantation on peripheral VA ECMO, conversion to a central VA ECMO platform is preferred in the setting of poor flow or central hypoxemia. Importantly, all patients at our institution requiring MCS during lung transplantation are supported on a modified circuit that allows for rapid conversion from VA ECMO to full cardiopulmonary bypass (CPB) as needed.

We propose a simple and technically feasible algorithm to facilitate the intraoperative conversion of VV, VPa, and VA ECMO patients to a modified central VA ECMO/CPB platform during bilateral lung transplantation.