Bloodless Lung Transplantation: Comparison Between Two Central Venoarterial ECMO Anticoagulation Strategies and Their Impact on Lung Transplant Outcomes.

Objective: We report differences between two anticoagulation protocols during VA-ECMO intraoperative support and their effects on outcomes following lung transplantation.

Methods: We performed a retrospective analysis of patients undergoing double lung transplantation with intraoperative VA-ECMO from 1/1/2016 - 12/30/2023. Two distinct anticoagulation protocols were in place during this period. One included targeted ACT > 180s at all times with protamine reversal after decannulation. The second included 75 Ui of heparin at the time of cannulation with no redosing plus a TXA infusion after ECMO initiation.

Results: A total of 116 patients (46 low heparin, 70 standard) were included in the analysis. Cannulation strategies and ECMO circuit were equivalent between the groups. The low heparin protocol group had a shorter surgical time (7.28 vs 8.53 hours, p<0.001) and required significantly less intraoperative pRBC (median 4.37 vs. 0 units p<0.001), FFP (median 2 vs 0 units, p<0.001), platelets (median 1 vs 0 units, p<0.001), cryoprecipitate (median 0 vs 0 units, p<0.001), and total blood products (median 9 vs 0 units, p<0.001) compared to the standard group. There were no differences in rates of DVT (p=0.13), airway dehiscence (p>0.99), pneumonia (p=0.38), or acute kidney injury require renal replacement therapy (p=0.59). There was no difference in rates of severe grade 3 PGD at 72 hours post-transplant (p=0.42).

Conclusion: Our low heparin VA-ECMO protocol for intraoperative support during lung transplantation led to a significant reduction of blood product utilization. While this did not translate to a reduced PGD 3 rates, the low heparin protocol was associated with similar post-operative outcomes.