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THE USE OF CARDIOPULMONARY BYPASS FOR LUNG TRANSPLANTATION IS NOT ASSOCIATED WITH MAJOR BLOOD LOSS OR INCREASED MORTALITY.

Brenken UPM, Mungroop HE, Boer WJ de*, Meuzelaar JJ*, Mannes GPM’.

Dept. of Anaesthesiology and Thorax Centre’, University Hospital Groningen, Oostersingel 59 9713 EZ Gronmgen, The Netherlands.

Introduction Since the early days of lung transplantation (LTX) there is discussion on the use of cardiopulmonary bypass (CPB). In most institutions the tendency is not to use CPB because one fears severe haemorrhage or inflammatory process associated with bypass. We had to use CPB in most cases. Therefore we searched the literature on the effects of CPB on blood loss and mortality and compared these with our results.

Patients and methods Since 1990 19 patients (8 female, 11 male); mean age 43 + 11 years) underwent LIX; fifteen were operated with the use of CPB, 6 unilateral CULT) and 9 bilateral (BLT) lung transplantation. Anaesthesia technique was a high dose opioid-midazolam infusion with oxygen in air. The indications for LTX and the use of CPB were as follows:

Ths mean bypass time was 273 f 58 iliirl. Aprstinin (2 A 1C’ EJ was administered in 9 cases. The extracorporal circuit was primed with a Human albumin/Ringer lactate solution and gas transfer was accomplished by a membrane oxygenator (Scimed R). CPB was indicated in 6 cases because of pulmonary hypertension, and in 9 patients because of untreatable hypoxemia, hypercarbia or diminished cardiac output caused by arrhythmias during surgical manipulation.

Results Mortalitv:There was no intraoperative death. Early mortality, defined as death within 2 months of surgery, was 1 patient. At present from all transplanted patients there are 17 alive with a follow-up of 2-24 months. Blood loss: In 18 patients (1 patient was not documented) the overall intraoperative blood loss was 1641 f 1378 (mean *SD). In the non-bypass group (4 patients: 3 ULT, 1 BLT) the blood loss was 725 *266 ml; in the bypass group (14 patients: 5 ULT, 9 BLT) 1904 f 1462 ml. In ULT we had a blood loss of 1653 f 1653 ml; the non-bypass group 717 +325 ml, the bypass group 2215 f 1918 ml. In BLT the total blood loss was 1632 + 1209 ml; the non-bypass patient 750 ml, the bypass group 1730 f 1240 ml. In all groups blood loss is higher with the use of CPB, but there is no statistical significance. One patient in the bypass group (6.67%) needed a rethoracotomy because of persistent postoperative blood loss. Graft function: none of the bypass group patients had clinical signs of an inflammatory process of the transplanted or native lungs.

In patients with primary pulmonary hypertension we regularly observed lung oedema of the transplanted lung due to the fact, that the graft received the entire cardiac output after declamping the arteria pulmonalis. The oedema could be treated such that no graft dysfunction resulted. Discussion Mortality after LTX is decreasing wrth more experience. One year survival rate is 68% (St. Louis, Aug. 1992, International Lung Transplant Registration). There are no exact data on whether the use of CPB increases mortality, generally severe haemorrhage is feared. In our series we had no operative death. One institution’ reports an operative mortality of 16%, all deaths were related to severe haemorrha

B e. It was not correlated to the use of CPB.

Another institution reports an intraoperative blood loss for BLT without CPB of 2.5 f 1.4 I. Blood loss in our series was less, even in the group where we used CPB. These data show that blood loss with the use of CPB in LTX is not as high as could be suspected from the literature. The effect of aprotinin could not be studied sufficiently because of the small number of patients where it was used.

Conclusion Whether or not to use CPB for LTX has to be decided for each patient during the operation. We believe that with frequent use of CPB, LlX can be performed with a minimum of early mortality and that blood loss is not as hiqh as thought in earlier reoorts.

ReMrences 1. Shennib H, Noirckarc M, Ernst P, et al. Double-Lung

Transplantation for Cystic Fibrosis. Ann Thorac Surg 1992;54:27-32.

2. Raffin L, MicheCCherqui M, et al. Anesthesia for bilateral Lung Transplantation Without Cardiopulmonary Bypass: Initial Experience and Review of Intraoperative Problems. Journal of Cardiothoracic and Vascular Anesthesia 1992$X4):409-417.