Management of primary graft dysfunction after lung transplantation with extracorporeal life support: an evidence-based review

Primary graft dysfunction (PGD) is a complex inflammatory syndrome that can lead to respiratory failure after lung transplantation (LTx). The pathogenesis of PGD is multifactorial and can be driven by attributes of both the donor and recipient, perioperative characteristics, and technical handling of the graft. Despite significant advancements in patient and donor selection, perioperative management and surgical technique, PGD is still a major contributor to morbidity and mortality after lung transplant. Although there are no known durable treatment options for PGD after LTx, an increasing body of evidence and experience in high-volume lung transplant centers show that extracorporeal life support (ECLS) is a reliable option for both preventing PGD and supporting critically ill patients with PGD. Both veno-venous (V-V) ECLS and veno-arterial (V-A) ECLS are proven and feasible strategies for mitigating the morbidity and mortality associated with post-LTx PGD. In this evidence-based review, we provide an overview of the epidemiology and physiology of PGD as well as a growing body of data that supports ECLS as a major tool to manage PGD. We describe the role of ECMO in PGD prevention and management, worldwide outcomes of LTx with ECLS support, and outline our step-wise approach to managing this complex respiratory syndrome leading up to institution of ECLS.